Provider Demographics
NPI:1588628903
Name:WAGNER PSYCHOLOGICAL ASSOCIATES
Entity Type:Organization
Organization Name:WAGNER PSYCHOLOGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:215-331-7707
Mailing Address - Street 1:2824 COTTMAN AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-1400
Mailing Address - Country:US
Mailing Address - Phone:215-331-7707
Mailing Address - Fax:215-331-7790
Practice Address - Street 1:2824 COTTMAN AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-1400
Practice Address - Country:US
Practice Address - Phone:215-331-7707
Practice Address - Fax:215-331-7790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-003973-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty