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NPI Code Detail

MEDICARE: SUSAN D. WAGNER MFT

MEDICARE: SUSAN D. WAGNER MFT
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
1106H00000XMarriage & Family TherapistMFC33511CA

General Provider Information

NPI Number : 1629220801
Entity Type Code : Individual
Provider Name (Legal Business Name) : SUSAN D. WAGNER MFT
Provider Business Mailing Address
First Line : 1549 PACIFIC AVE
Second Line :
City : SANTA ROSA
State : CA
Zip : 95404-3507
Country : US
Telephone Number : 707-545-7706
Fax Number : 707-887-2035
Provider Business Practice Location Address
First Line : 1549 PACIFIC AVE
Second Line :
City : SANTA ROSA
State : CA
Zip : 95404-3507
Country : US
Telephone Number : 707-545-7706
Fax Number : 707-887-2035
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/19/2008
Last Update Date : 10/19/2008

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