Basic Information
| Provider Information | |||||||||
| NPI: | 1831204270 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. C.A.S.A.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 73 S CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115805402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168729698 | ||||||||
| FaxNumber: | 5168728758 | ||||||||
| Practice Location | |||||||||
| Address1: | 73 S CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115805402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168729698 | ||||||||
| FaxNumber: | 5168728758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| 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 | 101YA0400X | 10434 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.