Provider Demographics
NPI:1497852370
Name:WAGNER, SEAN M (LCP)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 E C AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:KS
Mailing Address - Zip Code:67068-1622
Mailing Address - Country:US
Mailing Address - Phone:620-532-2513
Mailing Address - Fax:
Practice Address - Street 1:760 W D AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:KS
Practice Address - Zip Code:67068-1266
Practice Address - Country:US
Practice Address - Phone:620-532-3895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0196103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS393288OtherBCBS