Provider Demographics
NPI:1346497203
Name:WAGNER, ADRIANA L
Entity Type:Individual
Prefix:MRS
First Name:ADRIANA
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11320 SCRIBNER STATION LN
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547
Mailing Address - Country:US
Mailing Address - Phone:813-707-4774
Mailing Address - Fax:813-949-7535
Practice Address - Street 1:11320 SCRIBNER STATION LN
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547
Practice Address - Country:US
Practice Address - Phone:813-707-4774
Practice Address - Fax:813-949-7535
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL222Q00000XMedicaid