Provider Demographics
NPI:1245455138
Name:WAGNER, MARA SANADI (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARA
Middle Name:SANADI
Last Name:WAGNER
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 1:23 POKONOKET AVE
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-2320
Mailing Address - Country:US
Mailing Address - Phone:978-443-6769
Mailing Address - Fax:978-440-9914
Practice Address - Street 1:23 POKONOKET AVE
Practice Address - Street 2:
Practice Address - City:SUDBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-2320
Practice Address - Country:US
Practice Address - Phone:978-443-6769
Practice Address - Fax:978-440-9914
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4122103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04034Medicare ID - Type UnspecifiedBCBSMA