Provider Demographics
NPI:1023023553
Name:WAGNER, AUREEN P (PHD)
Entity Type:Individual
Prefix:DR
First Name:AUREEN
Middle Name:P
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 REGENCY PKWY STE 204
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-8507
Mailing Address - Country:US
Mailing Address - Phone:919-371-8230
Mailing Address - Fax:919-469-8639
Practice Address - Street 1:2000 REGENCY PKWY STE 204
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8507
Practice Address - Country:US
Practice Address - Phone:919-371-8230
Practice Address - Fax:919-469-8639
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010893103TC0700X
NCNC3973103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY102026FCMedicare UPIN
NYP040010893Medicare UPIN
NYP030010893Medicare UPIN
NYP010010893Medicare UPIN
NY5927745Medicare UPIN