Provider Demographics
NPI:1467613323
Name:WAGNER, LISA DONETTE (LMSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DONETTE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7619 PORTAL DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77071-1828
Mailing Address - Country:US
Mailing Address - Phone:713-995-9347
Mailing Address - Fax:713-995-9347
Practice Address - Street 1:5420 DASHWOOD DR
Practice Address - Street 2:STE 210
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-5357
Practice Address - Country:US
Practice Address - Phone:713-839-9898
Practice Address - Fax:713-839-9494
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX09909OtherSOCIAL WORK LICENSE
TX180057502Medicaid
TX180057501Medicaid
TX1649384991OtherNPI