Provider Demographics
NPI:1376147157
Name:WAGNER, KATHERINE MAUREEN
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MAUREEN
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 1:1103 S MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-3005
Mailing Address - Country:US
Mailing Address - Phone:773-329-3890
Mailing Address - Fax:
Practice Address - Street 1:444 N NORTHWEST HWY STE 220
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3271
Practice Address - Country:US
Practice Address - Phone:630-269-2886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty