Provider Demographics
NPI:1578731725
Name:WAGNER, LISA LOUISE (MA, CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LOUISE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5040 VILLA LINDE PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3445
Mailing Address - Country:US
Mailing Address - Phone:810-732-4250
Mailing Address - Fax:810-732-0444
Practice Address - Street 1:5040 VILLA LINDE PKWY STE A
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3445
Practice Address - Country:US
Practice Address - Phone:810-732-4250
Practice Address - Fax:810-732-0444
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000283231H00000X
MI3501002468237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1578731725Medicaid