Provider Demographics
NPI:1376964114
Name:WAGERS, JUSTINA PITTMAN (PSYD)
Entity Type:Individual
Prefix:
First Name:JUSTINA
Middle Name:PITTMAN
Last Name:WAGERS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CAMPUS BOX 345
Mailing Address - Street 2:CU-BOULDER DEPT OF PSYCHOLOGY AND NEUROSCIENCE
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80309-0345
Mailing Address - Country:US
Mailing Address - Phone:303-442-2532
Mailing Address - Fax:
Practice Address - Street 1:1777 EXPOSITION DR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2628
Practice Address - Country:US
Practice Address - Phone:303-442-2532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical