Provider Demographics
NPI:1942066386
Name:WAGNER, RICHARD C
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
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 1:4083 OWL CREEK RD UNIT D
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-9048
Mailing Address - Country:US
Mailing Address - Phone:740-648-7399
Mailing Address - Fax:
Practice Address - Street 1:218 E NORTH ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1148
Practice Address - Country:US
Practice Address - Phone:740-947-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health