Provider Demographics
NPI:1164767752
Name:WAGNER, NANCY (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:BCBA
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 14597
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76094-1597
Mailing Address - Country:US
Mailing Address - Phone:817-277-8870
Mailing Address - Fax:
Practice Address - Street 1:3605 W PIONEER PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-4598
Practice Address - Country:US
Practice Address - Phone:817-277-8870
Practice Address - Fax:817-277-8875
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-07-3398103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst