Provider Demographics
NPI:1073103826
Name:WAGNER, ALYSSA NICOLE
Entity Type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:NICOLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1883 RIALTO CT
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-4170
Mailing Address - Country:US
Mailing Address - Phone:559-486-9368
Mailing Address - Fax:
Practice Address - Street 1:2550 W CLINTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-4206
Practice Address - Country:US
Practice Address - Phone:559-255-9117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)