Provider Demographics
NPI:1164964037
Name:WAGMAN, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:WAGMAN
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 1:81268 AVENIDA TRES LAGUNAS
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92203-7546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81268 AVENIDA TRES LAGUNAS
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92203-7546
Practice Address - Country:US
Practice Address - Phone:818-970-4913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical