Healthcare Provider Details

I. General information

NPI: 1174652440
Provider Name (Legal Business Name): BURL WAGENHEIM PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 IMPERIAL HWY HB 226
DOWNEY CA
90242-3456
US

IV. Provider business mailing address

PO BOX 3335
SEAL BEACH CA
90740-2335
US

V. Phone/Fax

Practice location:
  • Phone: 562-401-6320
  • Fax:
Mailing address:
  • Phone: 562-401-6329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY 16594
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: