Individual
DR. DENNIS E WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
ED.D.
Contact information
Practice address
1169 EASTERN PKWY STE 2238, LOUISVILLE, KY 40217-1444
(502) 718-9114
(502) 479-3561
Mailing address
1806 RICHMOND DR, LOUISVILLE, KY 40205-1410
(502) 718-9114
(502) 479-3561
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
0810
KY
103TC0700X
Clinical Psychologist
Primary
128987
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000501117
ANTHEM
KY
05
—
89008106
—
KY
01
—
K113410
MEDICARE
KY
Enumeration date
07/13/2006
Last updated
07/21/2022
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