Provider Demographics
NPI:1861236267
Name:WAGNER, CRYSTAL DANIELLE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DANIELLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6685 SULLIVAN RD
Mailing Address - Street 2:
Mailing Address - City:GREENWELL SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70739-3112
Mailing Address - Country:US
Mailing Address - Phone:225-960-2403
Mailing Address - Fax:
Practice Address - Street 1:6685 SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:GREENWELL SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70739-3112
Practice Address - Country:US
Practice Address - Phone:225-960-2403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician