Provider Demographics
NPI:1649384991
Name:LISA WAGNER
Entity Type:Organization
Organization Name:LISA WAGNER
Other - Org Name:WAGNER CONSULTANT SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:832-563-3237
Mailing Address - Street 1:7619 PORTAL DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77071-1828
Mailing Address - Country:US
Mailing Address - Phone:832-563-3237
Mailing Address - Fax:713-995-9348
Practice Address - Street 1:5420 DASHWOOD DR
Practice Address - Street 2:SUITE 210
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-5357
Practice Address - Country:US
Practice Address - Phone:713-839-9898
Practice Address - Fax:713-839-9494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX09909104100000X
261QF0050X, 261QM0850X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180057501Medicaid
TX180057502Medicaid
TX09909OtherSOCIAL WORK LICENSE NUMBER