Provider Demographics
NPI:1184876096
Name:WAGNER, KAREN R (PH D, BCBA-D, PHD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:R
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PH D, BCBA-D, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 SOLUTIONS WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3620
Mailing Address - Country:US
Mailing Address - Phone:321-639-9800
Mailing Address - Fax:321-639-6007
Practice Address - Street 1:550 SOLUTIONS WAY
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3620
Practice Address - Country:US
Practice Address - Phone:321-639-9800
Practice Address - Fax:321-639-6007
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7979101YM0800X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019422900Medicaid