Provider Demographics
NPI:1558461749
Name:KRISTINE T. WAGNER, PH.D, INC.
Entity type:Organization
Organization Name:KRISTINE T. WAGNER, PH.D, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:951-695-7400
Mailing Address - Street 1:PO BOX 892143
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92589-2143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27393 YNEZ RD
Practice Address - Street 2:SUITE 153
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5604
Practice Address - Country:US
Practice Address - Phone:951-695-7400
Practice Address - Fax:951-695-7144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18320103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ01448ZMedicare ID - Type UnspecifiedMEDICARE GROUP
P60902Medicare UPIN
OPL183200Medicare ID - Type UnspecifiedINDIVIDUAL #