Provider Demographics
NPI:1538236757
Name:WAGNER, DAVID MICHAEL (LMHC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MICHAEL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8335 40TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-3934
Mailing Address - Country:US
Mailing Address - Phone:727-344-0315
Mailing Address - Fax:727-344-0315
Practice Address - Street 1:8335 40TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-3934
Practice Address - Country:US
Practice Address - Phone:727-344-0315
Practice Address - Fax:727-344-0315
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH1455101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH1455OtherLMHC LICENSE NUMBER