Provider Demographics
NPI:1588211437
Name:WAGNER, CRAIG PHILLIP (PHD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:PHILLIP
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 POINTE DR STE 314
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3651
Mailing Address - Country:US
Mailing Address - Phone:714-672-9470
Mailing Address - Fax:
Practice Address - Street 1:555 POINTE DR STE 314
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3651
Practice Address - Country:US
Practice Address - Phone:714-672-9470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16195103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical