Provider Demographics
NPI:1073887626
Name:WAGNER, HOGAN (BA)
Entity Type:Individual
Prefix:
First Name:HOGAN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4880 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7783
Mailing Address - Country:US
Mailing Address - Phone:805-644-7827
Mailing Address - Fax:877-644-7545
Practice Address - Street 1:299 W HILLCREST DR STE 110
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-7824
Practice Address - Country:US
Practice Address - Phone:805-379-1401
Practice Address - Fax:877-644-7545
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst