Healthcare Provider Details

I. General information

NPI: 1750652871
Provider Name (Legal Business Name): FRANK DOUGLAS WAGNER MA, CMT, NRMT, LCAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W 98TH ST APT 8BF
NEW YORK NY
10025-5563
US

IV. Provider business mailing address

315 W 98TH ST APT 8BF
NEW YORK NY
10025-5563
US

V. Phone/Fax

Practice location:
  • Phone: 212-316-4939
  • Fax:
Mailing address:
  • Phone: 212-316-4939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number000572-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: