Provider Demographics
NPI:1720583842
Name:WAGNER, BRADLEY JAY (LAC)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:JAY
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:140 N RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-1704
Mailing Address - Country:US
Mailing Address - Phone:406-532-9900
Mailing Address - Fax:406-532-9901
Practice Address - Street 1:1321 WYOMING ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-1725
Practice Address - Country:US
Practice Address - Phone:406-532-9901
Practice Address - Fax:406-532-9901
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT29887101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)