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General NPI Number Information
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NPI Number | 1811293475
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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 | 01/31/2011
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Last Update Date | 01/31/2011
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Provider Practice Location Address
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Address Line | 455 E GRAND RIVER AVE SUITE 204
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City | BRIGHTON
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State | MI
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Zip | 48116-1551
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Country | US
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Telephone | 810-494-1700
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Fax | 810-494-0223
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Provider Business Mailing Address
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Address Line | 4970 NORTHWIND DR SUITE 226
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City | EAST LANSING
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State | MI
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Zip | 48823-5080
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Country | US
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Telephone | 517-336-1940
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Fax | 517-336-1944
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Authorized Official
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Title or Position | AUDIOLOGIST
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Name | MRS. LISA WAGNER
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Credential | MA, CCC-A
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Telephone | 517-336-1940
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | 1601000283
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License Number State | MI
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