Provider Demographics
NPI:1609421536
Name:JOHN WAGNER PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:JOHN WAGNER PSYCHOLOGICAL SERVICES LLC
Other - Org Name:JOHN WAGNER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:937-620-0542
Mailing Address - Street 1:7374 READING RD STE 110
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45237-3409
Mailing Address - Country:US
Mailing Address - Phone:937-620-0542
Mailing Address - Fax:513-299-0537
Practice Address - Street 1:7374 READING RD STE 110
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45237-3409
Practice Address - Country:US
Practice Address - Phone:937-620-0542
Practice Address - Fax:513-299-0537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-07
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty