Provider Demographics
NPI:1659685378
Name:WAGNER, THERESA RENEE (BCABA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:RENEE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 MADISON OAKS CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-7672
Mailing Address - Country:US
Mailing Address - Phone:704-839-6252
Mailing Address - Fax:
Practice Address - Street 1:2711 MADISON OAKS CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-7672
Practice Address - Country:US
Practice Address - Phone:704-839-6252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst