Provider Demographics
NPI:1861507428
Name:WEGNER, JAMES THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:THOMAS
Last Name:WEGNER
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 1:57 OLD ROAD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880
Mailing Address - Country:US
Mailing Address - Phone:203-254-2842
Mailing Address - Fax:
Practice Address - Street 1:57 OLD ROAD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880
Practice Address - Country:US
Practice Address - Phone:203-254-2842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1174103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT6800000757Medicare ID - Type Unspecified