Provider Demographics
NPI:1114196680
Name:WAGNER, KATJE (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:KATJE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 NW KEARNEY ST STE 23
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1465
Mailing Address - Country:US
Mailing Address - Phone:503-313-5733
Mailing Address - Fax:
Practice Address - Street 1:1942 NW KEARNEY ST STE 23
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1465
Practice Address - Country:US
Practice Address - Phone:503-313-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist