Basic Information
| Provider Information | |||||||||
| NPI: | 1720587553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | GLAVIS | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 46314 TIMINE WAY | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978019417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419669830 | ||||||||
| FaxNumber: | 5412787568 | ||||||||
| Practice Location | |||||||||
| Address1: | 46314 TIMINE WAY | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419669830 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2018 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 17-CRM-217 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 175T00000X | THW000002415 | OR | N | 405300000X | 17-CRM-217 | OR | Y |
No ID Information.