Provider Demographics
NPI:1285027011
Name:WAGNER, CHRISTINE (BA)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6714 KELLY ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15208-1717
Mailing Address - Country:US
Mailing Address - Phone:412-864-5323
Mailing Address - Fax:412-361-4791
Practice Address - Street 1:6714 KELLY ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15208-1717
Practice Address - Country:US
Practice Address - Phone:412-864-5323
Practice Address - Fax:412-361-4791
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA261QM2800X261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone