MEDICARE: WAGNER PSYCHOLOGICAL ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PS-003973-L	PA

General Provider Information

NPI Number	:	1588628903
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAGNER PSYCHOLOGICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	2824 COTTMAN AVE
Second Line	:	SUITE 8
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1400
Country	:	US
Telephone Number	:	215-331-7707
Fax Number	:	215-331-7790

Provider Business Practice Location Address
First Line	:	2824 COTTMAN AVE
Second Line	:	SUITE 8
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1400
Country	:	US
Telephone Number	:	215-331-7707
Fax Number	:	215-331-7790

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. MARK S. WAGNER
Credential	:	PH.D.
Telephone Number	:	215-331-7707

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	08/22/2020

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