Healthcare Provider Details

I. General information

NPI: 1235128331
Provider Name (Legal Business Name): VELMA WAGNER-ADAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: VELMA WAGNER M.A., L.P.

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 HARRIET AVE
MINNEAPOLIS MN
55409-1443
US

IV. Provider business mailing address

4048 PLEASANT AVE
MINNEAPOLIS MN
55409-1545
US

V. Phone/Fax

Practice location:
  • Phone: 612-877-1436
  • Fax: 612-822-1850
Mailing address:
  • Phone: 612-824-4719
  • Fax: 612-822-1850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP0320
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: