Provider Demographics
NPI:1700801487
Name:WAGNER, JOHN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7664 SLATE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-8158
Mailing Address - Country:US
Mailing Address - Phone:614-863-2399
Mailing Address - Fax:614-863-4040
Practice Address - Street 1:7664 SLATE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-8158
Practice Address - Country:US
Practice Address - Phone:614-863-2399
Practice Address - Fax:614-863-4040
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5746103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist