Healthcare Provider Details

I. General information

NPI: 1336457514
Provider Name (Legal Business Name): DANA BETH WAGNER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2010
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 BAY SCOTT CIR SUITE 109
NAPERVILLE IL
60540-1129
US

IV. Provider business mailing address

1819 BAY SCOTT CIR SUITE 109
NAPERVILLE IL
60540-1129
US

V. Phone/Fax

Practice location:
  • Phone: 630-357-2456
  • Fax: 630-357-2482
Mailing address:
  • Phone: 630-357-2456
  • Fax: 630-357-2482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.006933
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: