Provider Demographics
NPI:1164464632
Name:WEGENER, STEPHEN (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:WEGENER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64407
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2905
Practice Address - Country:US
Practice Address - Phone:410-532-4701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03173103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD338130700Medicaid
MD338130700Medicaid
MDR62677Medicare UPIN