Provider Demographics
NPI:1821130188
Name:WAGENER, KAYLA M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:M
Last Name:WAGENER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6971 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50324-1540
Mailing Address - Country:US
Mailing Address - Phone:515-274-8748
Mailing Address - Fax:
Practice Address - Street 1:6971 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50324-1540
Practice Address - Country:US
Practice Address - Phone:515-274-8748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA23852OtherWELLMARK LEGACY NUMBER
IA250068OtherMIDLANDS CHOICE LEGACY