Provider Demographics
NPI:1225308836
Name:WAGNER, KYLE W (LPC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:W
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2884 INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 13
Mailing Address - City:BETHEL PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15102-2580
Mailing Address - Country:US
Mailing Address - Phone:412-945-0692
Mailing Address - Fax:412-774-2627
Practice Address - Street 1:2884 INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 13
Practice Address - City:BETHEL PARK
Practice Address - State:PA
Practice Address - Zip Code:15102-2580
Practice Address - Country:US
Practice Address - Phone:412-945-0692
Practice Address - Fax:412-774-2627
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0800066101YP2500X
PAPC006856101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional