Provider Demographics
NPI:1215212931
Name:VAGT, ANDREA M (DIPLAC LAC)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:M
Last Name:VAGT
Suffix:
Gender:F
Credentials:DIPLAC LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7755 PARAGON RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4055
Mailing Address - Country:US
Mailing Address - Phone:937-671-8737
Mailing Address - Fax:
Practice Address - Street 1:6700 LOOP RD BLDG 4
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2161
Practice Address - Country:US
Practice Address - Phone:937-671-8737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH000210171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist