Healthcare Provider Details

I. General information

NPI: 1699304311
Provider Name (Legal Business Name): ALLISON WAGNER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 EXECUTIVE DRIVE SUITE 315
SAN DIEGO CA
92121-2360
US

IV. Provider business mailing address

4510 EXECUTIVE DR STE 315
SAN DIEGO CA
92121-3029
US

V. Phone/Fax

Practice location:
  • Phone: 203-667-6097
  • Fax:
Mailing address:
  • Phone: 203-667-6097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number32859
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: