=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760577340
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL DALE WAGNER PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 06/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5415 MEDALLION DR W
-----------------------------------------------------
City | WESTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43082-9194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-218-8769
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5415 MEDALLION DR W
-----------------------------------------------------
City | WESTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43082-9194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-218-8769
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 4636
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 4636
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------