Provider Demographics
NPI:1043768237
Name:WAGENBERG, NICOLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:WAGENBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:NICOLA
Other - Middle Name:
Other - Last Name:WAGENBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1415 BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1908
Mailing Address - Country:US
Mailing Address - Phone:415-305-1425
Mailing Address - Fax:
Practice Address - Street 1:925 THE ALAMEDA
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-2310
Practice Address - Country:US
Practice Address - Phone:510-698-2491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27376103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical