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General NPI Number Information
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NPI Number | 1649384991
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Entity Type | Organization
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Legal Business Name | LISA WAGNER
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Dates
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Enumeration Date | 08/17/2006
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Last Update Date | 06/23/2008
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Provider Practice Location Address
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Address Line | 5420 DASHWOOD DR SUITE 210
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City | HOUSTON
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State | TX
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Zip | 77081-5357
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Country | US
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Telephone | 713-839-9898
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Fax | 713-839-9494
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Provider Business Mailing Address
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Address Line | 7619 PORTAL DR
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City | HOUSTON
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State | TX
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Zip | 77071-1828
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Country | US
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Telephone | 832-563-3237
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Fax | 713-995-9348
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Authorized Official
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Title or Position | SOCIAL WORKER
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Name | MS. LISA D WAGNER
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Credential | LMSW
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Telephone | 832-563-3237
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QF0050X
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Taxonomy Name | Non-Surgical Family Planning Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 09909
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License Number State | TX
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