Provider Demographics
NPI:1790050433
Name:WAGNER, ANTHONY JOSEPH
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOSEPH
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 1:5285 SW NASH AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-9312
Mailing Address - Country:US
Mailing Address - Phone:503-459-7199
Mailing Address - Fax:
Practice Address - Street 1:3878 BEVERLY AVE NE
Practice Address - Street 2:BUILDING H
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1394
Practice Address - Country:US
Practice Address - Phone:503-576-4692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor