Provider Demographics
NPI:1295938074
Name:WAGNER, KIMBERLY EILEEN (MA)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:EILEEN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2870 4TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-6298
Mailing Address - Country:US
Mailing Address - Phone:858-997-3457
Mailing Address - Fax:619-297-0470
Practice Address - Street 1:2870 4TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6298
Practice Address - Country:US
Practice Address - Phone:858-997-3457
Practice Address - Fax:619-297-0470
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health