Healthcare Provider Details

I. General information

NPI: 1013415199
Provider Name (Legal Business Name): SAMANTHA BROOKE WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230 WARING CT STE A
OCEANSIDE CA
92056-4509
US

IV. Provider business mailing address

3230 WARING CT STE A
OCEANSIDE CA
92056-4509
US

V. Phone/Fax

Practice location:
  • Phone: 760-305-7528
  • Fax: 760-509-4410
Mailing address:
  • Phone: 760-305-7528
  • Fax: 760-509-4410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: