Provider Demographics
NPI:1548747827
Name:WAGNER, SETH (RBT)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 61 BOX 3030
Mailing Address - Street 2:
Mailing Address - City:NAYLOR
Mailing Address - State:MO
Mailing Address - Zip Code:63953-9414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:RR 61 BOX 3030
Practice Address - Street 2:
Practice Address - City:NAYLOR
Practice Address - State:MO
Practice Address - Zip Code:63953-9414
Practice Address - Country:US
Practice Address - Phone:573-429-1518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician