Provider Demographics
NPI:1376197723
Name:WAGNER, KASSIDY DIANE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:KASSIDY
Middle Name:DIANE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 S FITNESS PL
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6828
Mailing Address - Country:US
Mailing Address - Phone:208-957-6301
Mailing Address - Fax:208-228-0585
Practice Address - Street 1:449 S FITNESS PL
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6828
Practice Address - Country:US
Practice Address - Phone:208-957-6301
Practice Address - Fax:208-228-0585
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1-23-68300103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst