Provider Demographics
NPI:1467650143
Name:WAGNER, THOMAS (LPSYA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LPSYA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 W 22ND ST
Mailing Address - Street 2:# 2G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-2411
Mailing Address - Country:US
Mailing Address - Phone:212-691-7158
Mailing Address - Fax:
Practice Address - Street 1:88 UNIVERSITY PLACE
Practice Address - Street 2:SUITE 4E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-691-7158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY345OtherNYS PSYCHOANALYSIS LIC.