Provider Demographics
NPI:1558867051
Name:WAGNER, KATHRYN IRENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:IRENE
Last Name:WAGNER
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 1:8305 ROANOKE AVE APT C
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6278
Mailing Address - Country:US
Mailing Address - Phone:202-725-7249
Mailing Address - Fax:
Practice Address - Street 1:WASHINGTON DC VA MEDICAL CENTER 50 IRVING STREET NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20422-0001
Practice Address - Country:US
Practice Address - Phone:202-745-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY1001313103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical