Healthcare Provider Details

I. General information

NPI: 1174168819
Provider Name (Legal Business Name): ASHLEY WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MOBIL AVE STE A3
CAMARILLO CA
93010-6369
US

IV. Provider business mailing address

5746 KATHERINE ST
SIMI VALLEY CA
93063-4551
US

V. Phone/Fax

Practice location:
  • Phone: 855-295-3276
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: