Provider Demographics
NPI:1417476557
Name:WAGSTAFF, AMANDA (PHD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WAGSTAFF
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 4TH ST # 5A
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2350
Mailing Address - Country:US
Mailing Address - Phone:415-502-1914
Mailing Address - Fax:415-353-2400
Practice Address - Street 1:1825 4TH ST FL 5
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2350
Practice Address - Country:US
Practice Address - Phone:805-558-0601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-10
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30640103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist