Provider Demographics
NPI:1225181084
Name:WAGMAN, RICHARD J (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:WAGMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:DUFFY
Other - Middle Name:
Other - Last Name:WAGMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2238 E GINTER ROAD
Mailing Address - Street 2:SUNNYSIDE UNIFIED SCHOOL DISTRICT NO 12
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:95706
Mailing Address - Country:US
Mailing Address - Phone:520-545-2137
Mailing Address - Fax:520-545-2120
Practice Address - Street 1:2238 E GINTER ROAD
Practice Address - Street 2:SUNNYSIDE UNIFIED SCHOOL DISTRICT NO 12
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85706
Practice Address - Country:US
Practice Address - Phone:520-545-2137
Practice Address - Fax:520-545-2120
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1488103TC0700X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ540342Medicaid