Provider Demographics
NPI:1700423258
Name:WAGNER, LAURA ANN
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5509 S IRIS ST
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80123-7417
Mailing Address - Country:US
Mailing Address - Phone:720-334-0013
Mailing Address - Fax:
Practice Address - Street 1:7220 W JEFFERSON AVE STE 202
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80235-2023
Practice Address - Country:US
Practice Address - Phone:303-225-7673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician