Provider Demographics
NPI:1770106072
Name:WAGNER, SANDRA (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5069 SHADYMEADOW LN APT F
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-8290
Mailing Address - Country:US
Mailing Address - Phone:719-210-5667
Mailing Address - Fax:
Practice Address - Street 1:1800 S 35TH ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053-9688
Practice Address - Country:US
Practice Address - Phone:269-484-1121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401001058103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst