Provider Demographics
NPI:1518281609
Name:WAGNER, TARA LEE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LEE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5099 CAMEO TER
Mailing Address - Street 2:
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-8934
Mailing Address - Country:US
Mailing Address - Phone:410-967-3439
Mailing Address - Fax:410-785-3848
Practice Address - Street 1:5099 CAMEO TER
Practice Address - Street 2:
Practice Address - City:PERRY HALL
Practice Address - State:MD
Practice Address - Zip Code:21128-8934
Practice Address - Country:US
Practice Address - Phone:410-967-3439
Practice Address - Fax:410-785-3848
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst