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NPI Code Detail

MEDICARE: KELSEY WAGNER BT

MEDICARE: KELSEY WAGNER BT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1578272571
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELSEY WAGNER BT
Provider Business Mailing Address
First Line : 1075 WOODWARD AVE LOWR LEVEL
Second Line :
City : KINGSFORD
State : MI
Zip : 49802-4434
Country : US
Telephone Number : 906-828-2088
Fax Number : 906-771-8080
Provider Business Practice Location Address
First Line : 1075 WOODWARD AVE LOWR LEVEL
Second Line :
City : KINGSFORD
State : MI
Zip : 49802-4434
Country : US
Telephone Number : 906-828-2088
Fax Number : 906-771-8080
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/17/2022
Last Update Date : 11/17/2022

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Directions to “ KELSEY WAGNER BT” Practice Location

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