Provider Demographics
NPI:1982875852
Name:WAGNER, ROBERT MICHAEL (LP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHAEL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 SNOWDRIFT CIR E
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55119-5993
Mailing Address - Country:US
Mailing Address - Phone:612-272-2255
Mailing Address - Fax:
Practice Address - Street 1:160 EAST KELLOGG BLVD.
Practice Address - Street 2:SUITE 8500
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101
Practice Address - Country:US
Practice Address - Phone:651-266-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4010103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist