Basic Information
| Provider Information | |||||||||
| NPI: | 1316074115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | L. | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 5TH ST | ||||||||
| Address2: | # 300 | ||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700021865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048360000 | ||||||||
| FaxNumber: | 5048324040 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 5TH ST | ||||||||
| Address2: | # 300 | ||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700021865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048360000 | ||||||||
| FaxNumber: | 5048324040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2014 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.