Provider Demographics
NPI:1578674313
Name:WAGGENER, NATALIE MOSS (PHD)
Entity Type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:MOSS
Last Name:WAGGENER
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 1:1800 TOWN CENTER DR
Mailing Address - Street 2:STE 411
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190
Mailing Address - Country:US
Mailing Address - Phone:703-437-3236
Mailing Address - Fax:703-435-7422
Practice Address - Street 1:1800 TOWN CENTER DR
Practice Address - Street 2:STE 411
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-437-3236
Practice Address - Fax:703-435-7422
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001841103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA147400OtherANTHEM BCBS