Healthcare Provider Details

I. General information

NPI: 1467613323
Provider Name (Legal Business Name): LISA DONETTE WAGNER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5420 DASHWOOD DR STE 210
HOUSTON TX
77081-5357
US

IV. Provider business mailing address

7619 PORTAL DR
HOUSTON TX
77071-1828
US

V. Phone/Fax

Practice location:
  • Phone: 713-839-9898
  • Fax: 713-839-9494
Mailing address:
  • Phone: 713-995-9347
  • Fax: 713-995-9347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: