Provider Demographics
NPI:1184649402
Name:WAGNER, DENNIS E (EDD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 RICHMOND DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1410
Mailing Address - Country:US
Mailing Address - Phone:502-718-9114
Mailing Address - Fax:502-479-3561
Practice Address - Street 1:1169 EASTERN PKWY STE 2238
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1444
Practice Address - Country:US
Practice Address - Phone:502-718-9114
Practice Address - Fax:502-479-3561
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0810103TC0700X
KY128987103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000501117OtherANTHEM
KY89008106Medicaid
KYK113410OtherMEDICARE
KYR40032Medicare UPIN