Provider Demographics
NPI:1043233919
Name:WAGNER, TOM L
Entity Type:Individual
Prefix:DR
First Name:TOM
Middle Name:L
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:BOX 2784 MSU
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071
Mailing Address - Country:US
Mailing Address - Phone:270-759-1210
Mailing Address - Fax:270-753-6210
Practice Address - Street 1:509 MAIN ST
Practice Address - Street 2:DR TOM L WAGNER
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071
Practice Address - Country:US
Practice Address - Phone:270-759-1210
Practice Address - Fax:270-753-6210
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY319103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist