Provider Demographics
NPI:1306357116
Name:KNIGHT, LINDA ANN WAGNER (LP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:ANN WAGNER
Last Name:KNIGHT
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 CORTEZ ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-6549
Mailing Address - Country:US
Mailing Address - Phone:979-229-3362
Mailing Address - Fax:
Practice Address - Street 1:2001 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-1954
Practice Address - Country:US
Practice Address - Phone:979-822-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30797103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist