Healthcare Provider Details

I. General information

NPI: 1578731725
Provider Name (Legal Business Name): LISA LOUISE WAGNER MA, CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5040 VILLA LINDE PKWY STE A
FLINT MI
48532-3445
US

IV. Provider business mailing address

5040 VILLA LINDE PKWY STE A
FLINT MI
48532-3445
US

V. Phone/Fax

Practice location:
  • Phone: 810-732-4250
  • Fax: 810-732-0444
Mailing address:
  • Phone: 810-732-4250
  • Fax: 810-732-0444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1601000283
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: