Individual
LISA WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
706 W 17TH ST APT 2F, CHICAGO, IL 60616-1220
(630) 709-8252
Mailing address
706 W 17TH ST APT 2F, CHICAGO, IL 60616-1220
(630) 709-8252
Taxonomy
Speciality
Code
Description
License number
State
222Q00000X
Developmental Therapist
Primary
—
—
Other
Enumeration date
08/17/2021
Last updated
08/17/2021
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