Provider Demographics
NPI:1568628436
Name:WAGNER, KARIN A (PHD)
Entity Type:Individual
Prefix:DR
First Name:KARIN
Middle Name:A
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 1:9 LOCUST RD
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-9627
Mailing Address - Country:US
Mailing Address - Phone:917-583-2130
Mailing Address - Fax:
Practice Address - Street 1:9 LOCUST RD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11719-9627
Practice Address - Country:US
Practice Address - Phone:917-583-2130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015920103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P3586132OtherOXFORD
P3586132OtherOXFORD