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General NPI Number Information
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NPI Number | 1184649402
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Entity Type | Individual
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Provider Name | DENNIS E WAGNER ED.D.
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Gender | Male
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Dates
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Enumeration Date | 07/13/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1169 EASTERN PKWY STE 2238
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City | LOUISVILLE
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State | KY
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Zip | 40217-1444
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Country | US
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Telephone | 502-718-9114
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Fax | 502-479-3561
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Provider Business Mailing Address
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Address Line | 1806 RICHMOND DR
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City | LOUISVILLE
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State | KY
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Zip | 40205-1410
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Country | US
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Telephone | 502-718-9114
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Fax | 502-479-3561
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0810
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 128987
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License Number State | KY
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