Provider Demographics
NPI:1982654695
Name:WAGNER WIKLER, BONNIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:
Last Name:WAGNER WIKLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 WASHINGTON ST
Mailing Address - Street 2:706
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2110
Mailing Address - Country:US
Mailing Address - Phone:619-342-8095
Mailing Address - Fax:619-342-8095
Practice Address - Street 1:302 WASHINGTON ST
Practice Address - Street 2:706
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2110
Practice Address - Country:US
Practice Address - Phone:619-342-8095
Practice Address - Fax:619-342-8095
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20609103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical