Provider Demographics
NPI:1912064676
Name:WAGNER, DONNA MARIE
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4282
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-4282
Mailing Address - Country:US
Mailing Address - Phone:209-840-0347
Mailing Address - Fax:
Practice Address - Street 1:1601 YOSEMITE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2800
Practice Address - Country:US
Practice Address - Phone:209-341-1824
Practice Address - Fax:209-523-1296
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC33775106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist