Provider Demographics
NPI:1356441174
Name:WAGNER, CYNTHIA A (LLP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
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 1:15209 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-9570
Mailing Address - Country:US
Mailing Address - Phone:269-781-9119
Mailing Address - Fax:269-781-4347
Practice Address - Street 1:15209 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-9570
Practice Address - Country:US
Practice Address - Phone:269-781-9119
Practice Address - Fax:269-781-4347
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007919103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301007919OtherLICENSE
MI7509107630OtherBCBS OF MI