MEDICARE: BRITTANY WAGNER

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
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1811536311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRITTANY WAGNER

Provider Business Mailing Address
First Line	:	4532 PENNYPACK ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19136-2112
Country	:	US
Telephone Number	:	215-783-2362
Fax Number	:

Provider Business Practice Location Address
First Line	:	4532 PENNYPACK ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19136-2112
Country	:	US
Telephone Number	:	847-306-9843
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/31/2019
Last Update Date	:	12/31/2019

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Directions to “ BRITTANY WAGNER ” Practice Location

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