=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548045131
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMANTHA A. WAGNER, PHD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2023
-----------------------------------------------------
Last Update Date | 08/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20747 STERLINGTON DR
-----------------------------------------------------
City | LAND O LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34638-4317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-815-2947
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20747 STERLINGTON DR
-----------------------------------------------------
City | LAND O LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34638-4317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-815-2947
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. SAMANTHA ANN WAGNER
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 813-815-2947
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------