Provider Demographics
NPI:1013033398
Name:WAGNER, LESLIE ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LESLIE
Other - Middle Name:ANN
Other - Last Name:KAYE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:533 SAINT CLAIR ST
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1503
Mailing Address - Country:US
Mailing Address - Phone:313-978-7792
Mailing Address - Fax:313-936-1084
Practice Address - Street 1:533 SAINT CLAIR ST
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1503
Practice Address - Country:US
Practice Address - Phone:313-978-7792
Practice Address - Fax:313-936-1084
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012459103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1013033398OtherNPPES