=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558461749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRISTINE T. WAGNER, PH.D, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27393 YNEZ RD SUITE 153
-----------------------------------------------------
City | TEMECULA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92591-5604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-695-7400
-----------------------------------------------------
Fax | 951-695-7144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 892143
-----------------------------------------------------
City | TEMECULA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92589-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KRISTINE WAGNER
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 951-695-7400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY18320
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------