Provider Demographics
NPI:1356555791
Name:DUKE E. WAGNER,PH.D.,INC.
Entity type:Organization
Organization Name:DUKE E. WAGNER,PH.D.,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DUKE
Authorized Official - Middle Name:ELVIN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:808-254-5468
Mailing Address - Street 1:PO BOX 2192
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-9192
Mailing Address - Country:US
Mailing Address - Phone:808-254-5468
Mailing Address - Fax:808-262-4437
Practice Address - Street 1:970 N KALAHEO AVE
Practice Address - Street 2:A204
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-1801
Practice Address - Country:US
Practice Address - Phone:808-254-5468
Practice Address - Fax:808-262-4437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY298103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000003889OtherHMSA
HI00461901Medicaid