Provider Demographics
NPI:1841464799
Name:WAGNER, JAMES L (LMHP)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:DAKOTA CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68731-0268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:402 W 19TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-2639
Practice Address - Country:US
Practice Address - Phone:402-494-5265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2311101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE2311Medicaid