Provider Demographics
NPI:1184647356
Name:WAGNER, MARK S (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:WAGNER
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 1:2824 COTTMAN AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-1400
Mailing Address - Country:US
Mailing Address - Phone:215-331-7707
Mailing Address - Fax:215-331-7790
Practice Address - Street 1:2824 COTTMAN AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-1400
Practice Address - Country:US
Practice Address - Phone:215-331-7707
Practice Address - Fax:215-331-7790
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS 003973L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical