Provider Demographics
NPI:1972020659
Name:WAGNER, ALEXANDRIA (BCBA)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 89TH ST STE 306
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-1656
Mailing Address - Country:US
Mailing Address - Phone:877-264-6747
Mailing Address - Fax:
Practice Address - Street 1:1800 SUTTER ST STE 300
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2556
Practice Address - Country:US
Practice Address - Phone:877-264-6747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-26547103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst