Provider Demographics
NPI:1497828875
Name:WAGENBACH, PAULA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PAULA
Middle Name:
Last Name:WAGENBACH
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 1:1818 NE IRVING ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2238
Mailing Address - Country:US
Mailing Address - Phone:503-421-0092
Mailing Address - Fax:
Practice Address - Street 1:1818 NE IRVING ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2238
Practice Address - Country:US
Practice Address - Phone:503-421-0092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1575103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical