Provider Demographics
NPI:1598045841
Name:WAGNER, MICHAEL C (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N JEFFERSON ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-3500
Mailing Address - Country:US
Mailing Address - Phone:301-620-8700
Mailing Address - Fax:301-620-8710
Practice Address - Street 1:10 N JEFFERSON ST
Practice Address - Street 2:SUITE 403
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-3500
Practice Address - Country:US
Practice Address - Phone:301-620-8700
Practice Address - Fax:301-620-8710
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05275103T00000X
VA0810004819103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical