Provider Demographics
NPI:1114183357
Name:WAGNER, AMY M (EDS, BCABA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:EDS, BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1275
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33568-1275
Mailing Address - Country:US
Mailing Address - Phone:813-335-8296
Mailing Address - Fax:813-671-4645
Practice Address - Street 1:9402 BULLFROG CT
Practice Address - Street 2:
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-5100
Practice Address - Country:US
Practice Address - Phone:813-335-8296
Practice Address - Fax:813-671-4645
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst