Provider Demographics
NPI:1164062741
Name:WAGNER, DANIEL JACOB (BCBA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JACOB
Last Name:WAGNER
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18115 ANDREA CIR N UNIT 1
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1111
Mailing Address - Country:US
Mailing Address - Phone:818-462-1168
Mailing Address - Fax:
Practice Address - Street 1:14724 VENTURA BLVD STE 1110
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3511
Practice Address - Country:US
Practice Address - Phone:818-501-4240
Practice Address - Fax:818-501-0470
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-19-39963103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst