Provider Demographics
NPI:1891127890
Name:WAGNER, LEAORA L (MS, BCBA)
Entity Type:Individual
Prefix:MS
First Name:LEAORA
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 W. ORNDORFF COURT
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:MD
Mailing Address - Zip Code:21716-1219
Mailing Address - Country:US
Mailing Address - Phone:301-693-8479
Mailing Address - Fax:
Practice Address - Street 1:1043 ORNDORFF CT
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:MD
Practice Address - Zip Code:21716-1219
Practice Address - Country:US
Practice Address - Phone:301-693-8479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11314102103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst