Provider Demographics
NPI:1235128331
Name:WAGNER-ADAMS, VELMA
Entity Type:Individual
Prefix:
First Name:VELMA
Middle Name:
Last Name:WAGNER-ADAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VELMA
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LP
Mailing Address - Street 1:4048 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55409-1545
Mailing Address - Country:US
Mailing Address - Phone:612-824-4719
Mailing Address - Fax:612-822-1850
Practice Address - Street 1:4100 HARRIET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55409-1443
Practice Address - Country:US
Practice Address - Phone:612-877-1436
Practice Address - Fax:612-822-1850
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0320103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103058OtherUCARE
MN1G213WAOtherBLUECROSS BLUESHIELD