Healthcare Provider Details

I. General information

NPI: 1265922504
Provider Name (Legal Business Name): ALICIA WAGONER PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 MEDWAY NEW CARLISLE RD
MEDWAY OH
45341-9744
US

IV. Provider business mailing address

2675 MEDWAY NEW CARLISLE RD
MEDWAY OH
45341-9744
US

V. Phone/Fax

Practice location:
  • Phone: 937-856-7066
  • Fax:
Mailing address:
  • Phone: 937-856-7066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number8397
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: