Michael Dale Wagner, PHD

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

4636 Issued in OH

Practice address

5415 Medallion Dr W
Westerville, OH 43082-9194

Phone

(614) 218-8769

NPI assigned

Oct 3, 2006

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

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

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

Practice roles

Locations

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

• Mt. Airy Development, LLC

  • Psychiatric Hospital
  • Cincinnati, OH
  • NPI 1801405519
  Medicare reassignment NPD
• Enliven Health and Wellness LLC

  • Adult Medicine Physician
  • Columbus, OH
  • NPI 1538832894
  NPD Authorized official
• Mindbridge Integrated Health LLC

  • Clinical Social Worker
  • Delaware, OH
  • NPI 1942078753
  NPD (past)

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

{
    "created_epoch": "1159833600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1592611200000",
    "number": "1760577340",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5415 MEDALLION DR W",
            "city": "WESTERVILLE",
            "state": "OH",
            "postal_code": "430829194",
            "telephone_number": "614-218-8769"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5415 MEDALLION DR W",
            "city": "WESTERVILLE",
            "state": "OH",
            "postal_code": "430829194",
            "telephone_number": "614-218-8769"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "MICHAEL",
        "middle_name": "DALE",
        "name_prefix": "Dr.",
        "credential": "PHD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-10-03",
        "last_updated": "2020-06-20",
        "certification_date": "2020-06-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC2200X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical Child & Adolescent",
            "state": "OH",
            "license": "4636",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "OH",
            "license": "4636",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Vonicare Home Health Services
• Celeste Voss, MA
• Mary Beth Wade, LPN
• Christiana Wagner, SLP
• Heidi Renee' Wagner, ATR-BC, LSW
• Jemimah Muthoni Wainaina, LPN
• Wal-Mart Stores East LP
• Wal-Mart Stores East, LP
• Walgreen Co
• Heidi Beth Walker, MOTR/L

• Clinical Psychologist in Westerville, OH
• Providers in Westerville, OH by specialty
• Clinical Psychologist in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2020; 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.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.