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General NPI Number Information
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NPI Number | 1497852370
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Entity Type | Individual
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Provider Name | SEAN M. WAGNER LCP
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Gender | Male
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 760 W D AVE
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City | KINGMAN
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State | KS
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Zip | 67068-1266
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Country | US
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Telephone | 620-532-3895
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Fax |
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Provider Business Mailing Address
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Address Line | 419 E C AVE
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City | KINGMAN
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State | KS
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Zip | 67068-1622
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Country | US
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Telephone | 620-532-2513
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Fax |
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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 | 0196
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License Number State | KS
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