Provider Demographics
NPI:1346813763
Name:WAGNER, ALEXANDRA E
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:E
Last Name:WAGNER
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 1:919 RAWHIDE PL
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-5564
Mailing Address - Country:US
Mailing Address - Phone:805-765-5538
Mailing Address - Fax:
Practice Address - Street 1:9620 CHESAPEAKE DR STE 105
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1324
Practice Address - Country:US
Practice Address - Phone:714-834-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2024-05-17
Deactivation Date:2024-05-01
Deactivation Code:
Reactivation Date:2024-05-17
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician