MEDICARE: KURT JAMES WAGNER LMFT

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	106H00000X	Marriage & Family Therapist	79845	CA

General Provider Information

NPI Number	:	1841606225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KURT JAMES WAGNER LMFT

Provider Business Mailing Address
First Line	:	1590 MARKET ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94102-6007
Country	:	US
Telephone Number	:	415-504-3130
Fax Number	:

Provider Business Practice Location Address
First Line	:	1590 MARKET ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94102-6007
Country	:	US
Telephone Number	:	415-504-3130
Fax Number	:

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

Provider Enumeration Date	:	07/07/2014
Last Update Date	:	07/07/2014

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