1649384991 NPI number — LISA WAGNER

Table of content: (NPI 1649384991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649384991 NPI number — LISA WAGNER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LISA WAGNER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WAGNER CONSULTANT SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649384991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7619 PORTAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77071-1828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-563-3237
Provider Business Mailing Address Fax Number:
713-995-9348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5420 DASHWOOD DR
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77081-5357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-839-9898
Provider Business Practice Location Address Fax Number:
713-839-9494
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
LISA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
SOCIAL WORKER
Authorized Official Telephone Number:
832-563-3237

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  09909 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QF0050X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 180057501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180057502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09909 . This is a "SOCIAL WORK LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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