Provider Demographics
NPI:1912597139
Name:WAGNER, JAMES CAROL
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:CAROL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-9703
Mailing Address - Country:US
Mailing Address - Phone:309-357-1973
Mailing Address - Fax:
Practice Address - Street 1:111 HICKORY ST
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525-9703
Practice Address - Country:US
Practice Address - Phone:309-357-1973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician