Individual
LYLE WALTER WAGNER III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHD, LP
Contact information
Practice address
3907 COON RAPIDS BLVD NW, COON RAPIDS, MN 55433-2520
(320) 629-7600
(651) 925-0071
Mailing address
220 RAILROAD ST SE, PINE CITY, MN 55063-1540
(320) 629-7600
(651) 925-0071
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
5751
MN
Other
Enumeration date
06/04/2014
Last updated
06/04/2014
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