Healthcare Provider Details

I. General information

NPI: 1033555362
Provider Name (Legal Business Name): MICHAEL S WAGNER PH.D., LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3263 SACRAMENTO ST SUITE B
SAN FRANCISCO CA
94115-2054
US

IV. Provider business mailing address

3263 SACRAMENTO ST SUITE B
SAN FRANCISCO CA
94115-2054
US

V. Phone/Fax

Practice location:
  • Phone: 415-775-2533
  • Fax:
Mailing address:
  • Phone: 415-775-2533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberMFC23782
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC23782
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: