Provider Demographics
NPI:1346477510
Name:WAGNER, MELANIE BETH (MSED, BCBA)
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:BETH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12061 STONE CROSSING CIRCLE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635
Mailing Address - Country:US
Mailing Address - Phone:813-957-0866
Mailing Address - Fax:
Practice Address - Street 1:12061 STONE CROSSING CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-6228
Practice Address - Country:US
Practice Address - Phone:813-957-0866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst