Provider Demographics
NPI:1821145012
Name:WAGNER, WHITNEY (LMFT)
Entity Type:Individual
Prefix:MS
First Name:WHITNEY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 CHELSEA RD
Mailing Address - Street 2:#805
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2419
Mailing Address - Country:US
Mailing Address - Phone:626-786-8730
Mailing Address - Fax:626-289-5946
Practice Address - Street 1:180 S LAKE AVE
Practice Address - Street 2:STE. 320
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2663
Practice Address - Country:US
Practice Address - Phone:626-786-8730
Practice Address - Fax:626-289-5946
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC35601106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist