Individual
DR. BLAKE DOUGLAS WAGNER JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
1575 MARION AVE, MANSFIELD, OH 44906-3409
(419) 529-9941
(419) 529-0496
Mailing address
1575 MARION AVE, MANSFIELD, OH 44906-3409
(419) 529-9941
(419) 529-0496
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
I-4127
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000315185
ANTHEM
—
Enumeration date
01/18/2007
Last updated
09/02/2008
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