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General NPI Number Information
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NPI Number | 1841474814
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Entity Type | Organization
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Legal Business Name | WAGNER & ASSOCIATES PLLC
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Dates
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Enumeration Date | 12/26/2007
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Last Update Date | 01/25/2012
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Provider Practice Location Address
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Address Line | 143 E MERRITT ST
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City | PRESCOTT
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State | AZ
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Zip | 86301-2028
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Country | US
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Telephone | 928-445-5027
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Fax | 928-445-7071
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Provider Business Mailing Address
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Address Line | 143 E MERRITT ST
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City | PRESCOTT
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State | AZ
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Zip | 86301-2028
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Country | US
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Telephone | 928-445-5027
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Fax | 928-445-7071
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. RUSSELL WAGNER
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Credential | ED.D.
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Telephone | 928-445-5027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 1592
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License Number State | AZ
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