Provider Demographics
NPI:1548595440
Name:PATRICK A WAGNER PHD PC
Entity Type:Organization
Organization Name:PATRICK A WAGNER PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:317-398-8146
Mailing Address - Street 1:17330 W CENTER RD
Mailing Address - Street 2:SUITE 110-282
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2392
Mailing Address - Country:US
Mailing Address - Phone:317-446-9288
Mailing Address - Fax:
Practice Address - Street 1:1253 NORTH DEER RUN E DRIVE
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176
Practice Address - Country:US
Practice Address - Phone:317-398-8146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010493A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty