Provider Demographics
NPI:1346392065
Name:WAGNER, SYDNEY LYNN (MFT)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 GREGORY LN
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523
Mailing Address - Country:US
Mailing Address - Phone:925-798-3161
Mailing Address - Fax:
Practice Address - Street 1:401 GREGORY LN
Practice Address - Street 2:SUITE 108
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523
Practice Address - Country:US
Practice Address - Phone:925-798-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT38201106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist