Healthcare Provider Details

I. General information

NPI: 1013069061
Provider Name (Legal Business Name): BLAKE DOUGLAS WAGNER JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 09/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 MARION AVE
MANSFIELD OH
44906-3409
US

IV. Provider business mailing address

1575 MARION AVE
MANSFIELD OH
44906-3409
US

V. Phone/Fax

Practice location:
  • Phone: 419-529-9941
  • Fax: 419-529-0496
Mailing address:
  • Phone: 419-529-9941
  • Fax: 419-529-0496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberI-4127
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: