Provider Demographics
NPI:1972675486
Name:WAGNER, LYLE WALTER JR (PHD)
Entity type:Individual
Prefix:DR
First Name:LYLE
Middle Name:WALTER
Last Name:WAGNER
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 N SIBLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55355-2141
Mailing Address - Country:US
Mailing Address - Phone:320-693-7708
Mailing Address - Fax:320-434-2176
Practice Address - Street 1:236 N SIBLEY AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355
Practice Address - Country:US
Practice Address - Phone:320-693-7708
Practice Address - Fax:320-434-2176
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0681103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist