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NPI Code Detail

MEDICARE: MICHELLE WAGNER B.C.B.A

MEDICARE: MICHELLE WAGNER B.C.B.A
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior Analyst1095246CA

General Provider Information

NPI Number : 1407101843
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHELLE WAGNER B.C.B.A
Provider Business Mailing Address
First Line : 9755 LINCOLN VILLAGE DR
Second Line :
City : SACRAMENTO
State : CA
Zip : 95827-3334
Country : US
Telephone Number : 916-363-6103
Fax Number : 916-363-6294
Provider Business Practice Location Address
First Line : 9755 LINCOLN VILLAGE DR
Second Line :
City : SACRAMENTO
State : CA
Zip : 95827-3334
Country : US
Telephone Number : 916-363-6103
Fax Number : 916-363-6294
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/23/2012
Last Update Date : 10/08/2019

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