MEDICARE: AUDREY WAGNER PH.D.

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	4685	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W04524	OTHER	MA	BCBS

General Provider Information

NPI Number	:	1922047679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDREY WAGNER PH.D.

Provider Business Mailing Address
First Line	:	173 MOUNT AUBURN ST
Second Line	:
City	:	WATERTOWN
State	:	MA
Zip	:	02472-4005
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	173 MOUNT AUBURN ST
Second Line	:
City	:	WATERTOWN
State	:	MA
Zip	:	02472-4005
Country	:	US
Telephone Number	:	617-923-2468
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	07/08/2007

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