Provider Demographics
NPI:1467495952
Name:WAGNER-WETZEL, NANCY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:WAGNER-WETZEL
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 1:81 ALAN LOOP
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4434
Mailing Address - Country:US
Mailing Address - Phone:718-816-7102
Mailing Address - Fax:718-816-7102
Practice Address - Street 1:148 JACQUES AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3028
Practice Address - Country:US
Practice Address - Phone:917-797-9441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7876103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00979424Medicaid
NY680408OtherGHI
NY00979424Medicaid