Individual
MR. KEN WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
5729 S 1ST AVE, TUCSON, AZ 85706-4408
(520) 409-8507
Mailing address
4660W. EL CAMINO CERRO, TUCSON, AZ 85745
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
522501
BEHAVOIRAL HEALTH
—
05
—
522501
—
AZ
Enumeration date
09/11/2019
Last updated
09/11/2019
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