Provider Demographics
NPI:1689055824
Name:WAGNER, KURT
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11211 SE 82ND AVE STE O
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-7641
Mailing Address - Country:US
Mailing Address - Phone:503-722-6545
Mailing Address - Fax:503-655-8585
Practice Address - Street 1:11211 SE 82ND AVE STE O
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-7641
Practice Address - Country:US
Practice Address - Phone:503-722-6545
Practice Address - Fax:503-655-8585
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-13
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health