Healthcare Provider Details

I. General information

NPI: 1134738057
Provider Name (Legal Business Name): SCOTT T WAGONER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-3774
  • Fax: 317-944-8521
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number20043486A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number20043486B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: