Provider Demographics
NPI:1801760665
Name:WAGNER, CINDY
Entity type:Individual
Prefix:MRS
First Name:CINDY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11035 NE SANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2553
Mailing Address - Country:US
Mailing Address - Phone:503-258-4200
Mailing Address - Fax:
Practice Address - Street 1:9911 SE MOUNT SCOTT BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-6302
Practice Address - Country:US
Practice Address - Phone:509-203-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-03
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health