MEDICARE: LISA WAGNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM2500X	Medical Specialty Clinic/Center
3	261QF0050X	Non-Surgical Family Planning Clinic/Center
4	104100000X	Social Worker	09909	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	09909	OTHER	TX	SOCIAL WORK LICENSE NUMBER

General Provider Information

NPI Number	:	1649384991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA WAGNER

Provider Business Mailing Address
First Line	:	7619 PORTAL DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77071-1828
Country	:	US
Telephone Number	:	832-563-3237
Fax Number	:	713-995-9348

Provider Business Practice Location Address
First Line	:	5420 DASHWOOD DR
Second Line	:	SUITE 210
City	:	HOUSTON
State	:	TX
Zip	:	77081-5357
Country	:	US
Telephone Number	:	713-839-9898
Fax Number	:	713-839-9494

Authorized Official
Title or Position	:	SOCIAL WORKER
Name	:	MS. LISA D WAGNER
Credential	:	LMSW
Telephone Number	:	832-563-3237

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	06/23/2008

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Directions to “LISA WAGNER ” Practice Location

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