Provider Demographics
NPI:1275680779
Name:WAGNER, BRITT ELISIA (LLP)
Entity Type:Individual
Prefix:
First Name:BRITT
Middle Name:ELISIA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N ADELAIDE ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2614
Mailing Address - Country:US
Mailing Address - Phone:810-750-2720
Mailing Address - Fax:
Practice Address - Street 1:725 MASON ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2421
Practice Address - Country:US
Practice Address - Phone:810-257-1325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009571103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist