Provider Demographics
NPI:1801093745
Name:DEBORAH WAGNER PHD LLC
Entity type:Organization
Organization Name:DEBORAH WAGNER PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:RISKU
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:201-445-3299
Mailing Address - Street 1:1172 EAST RIDGEWOOD AVENUE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3928
Mailing Address - Country:US
Mailing Address - Phone:201-445-3299
Mailing Address - Fax:201-262-0425
Practice Address - Street 1:1172 EAST RIDGEWOOD AVENUE
Practice Address - Street 2:SUITE #2
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3928
Practice Address - Country:US
Practice Address - Phone:201-445-3299
Practice Address - Fax:201-262-0425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00358200103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty