Doctor Name: | DR. MATTHEW T. WAGNER |
NPI Number: | 1811203417 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | CLIN. PSYCHOLOGIST |
License Number: | PSY 19277 |
Business Practice Address: | 21633 Avenue 24 Chowchilla, CA - 936109650 |
Business Phone Number: | 5596656100 |
Business Fax Number: | |
Mailing Address: | 21633 Avenue 24, CHOWCHILLA |
State: | CA |
Postal Code: | 936109650 |
Phone Number: | 5596556100 |
Fax Number: | |
NPI Enumeration Date: | 08/20/2010 |
NPI Last Update Date: | 08/20/2010 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TF0000X |
License Number: | PSY 19277 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | CA |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Family |
Taxonomy Definition: |