Healthcare Provider Details

I. General information

NPI: 1174224844
Provider Name (Legal Business Name): LINCOLN EDWARD WAGNER MA, BCBA, LBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11731 S CANBERRA DR
SANDY UT
84094-5694
US

IV. Provider business mailing address

11731 S CANBERRA DR
SANDY UT
84094-5694
US

V. Phone/Fax

Practice location:
  • Phone: 325-642-8586
  • Fax: 801-758-3633
Mailing address:
  • Phone: 325-642-8586
  • Fax: 801-758-3633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number14279645-2506
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: