Provider Demographics
NPI:1114396694
Name:WAGNER, STEPHEN LEE (EDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LEE
Last Name:WAGNER
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38720 SALTWELL RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-8303
Mailing Address - Country:US
Mailing Address - Phone:330-424-9591
Mailing Address - Fax:330-424-9481
Practice Address - Street 1:38720 SALTWELL RD
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-8303
Practice Address - Country:US
Practice Address - Phone:330-424-9591
Practice Address - Fax:330-424-9481
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHKU1007163103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool