Healthcare Provider Details

I. General information

NPI: 1588587091
Provider Name (Legal Business Name): WAGNER PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 MONROE ST STE A9
SYLVANIA OH
43560-2208
US

IV. Provider business mailing address

1309 N HAVEN RD
TOLEDO OH
43615-4732
US

V. Phone/Fax

Practice location:
  • Phone: 419-452-0495
  • Fax:
Mailing address:
  • Phone: 419-452-0495
  • Fax: 419-273-0608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN WAGNER
Title or Position: OWNER
Credential: PMHNP
Phone: 419-452-0495