Provider Demographics
NPI:1780737924
Name:WAGNER, MARK (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:MARK
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
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:
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:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4472103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04365Medicare ID - Type UnspecifiedBCBS & MEDICARE ID