Provider Demographics
NPI:1548207178
Name:WAGNER-MICKLE, ANN MARIE (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:MARIE
Last Name:WAGNER-MICKLE
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MINNEAPOLIS VA MEDICAL CENTER
Mailing Address - Street 2:PTSR CLINIC 116A6, ONE VETERANS DRIVE
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417
Mailing Address - Country:US
Mailing Address - Phone:612-725-2000
Mailing Address - Fax:612-727-5633
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:MINNEAPOLIS VA MEDICAL CENTER, 116A6
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:612-725-2000
Practice Address - Fax:612-727-5633
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN4216103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical