Blake Douglas Wagner Jr., PH.D.

Primary specialty

PsychologistTaxonomy code 103T00000X

License

I-4127 Issued in OH

Practice address

1575 Marion Ave
Mansfield, OH 44906-3409

Phone

(419) 529-9941

Fax

(419) 529-0496

NPI assigned

Jan 18, 2007

Last updated

Sep 2, 2008By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in OH

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Psychologist

Education

Other, 1988

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

New Directions Eap IncGroup PAC ID 3375438609, 3 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

Practice roles

Locations

Networks

• KY PPO
• devoted network organization-8ee96498-f86e-45f6-9fc9-a0f06c1636f9
• devoted network organization-2d523d8e-e8f9-454a-bcd3-333df65bdbe8
• KY PPO C-SNP
• devoted network organization-598bd2d4-c652-473f-ba7a-132f674c8eb6
• devoted network organization-9f3dfbd3-4aa6-4c92-8e71-9c4ed35ce037
• OH PPO

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• New Directions Eap Inc.

  • Counselor
  • Mansfield, OH
  • NPI 1295887222
  Medicare reassignment Care Compare group NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169078400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1220313600000",
    "number": "1013069061",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1575 MARION AVE",
            "city": "MANSFIELD",
            "state": "OH",
            "postal_code": "449063409",
            "telephone_number": "419-529-9941",
            "fax_number": "419-529-0496"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1575 MARION AVE",
            "city": "MANSFIELD",
            "state": "OH",
            "postal_code": "449063409",
            "telephone_number": "419-529-9941",
            "fax_number": "419-529-0496"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "BLAKE",
        "middle_name": "DOUGLAS",
        "name_prefix": "Dr.",
        "name_suffix": "Jr.",
        "credential": "PH.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-01-18",
        "last_updated": "2008-09-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "OH",
            "license": "I-4127",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM",
            "identifier": "000000315185",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kayla S. Wade
• Robert E Wade
• Karen Sue Wagenhals, M.D.
• Rebecca A Wagers, CDCA
• Michael Waggle
• Brandon Wagner
• Catherine Marie Wagner, STNA
• Jessica Wagner, PA-C
• Meghan Wagner, LPCC
• Miranda Wagnitz

• Psychologist in Mansfield, OH
• Providers in Mansfield, OH by specialty
• Psychologist in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 2, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.