Provider Demographics
NPI:1174730972
Name:WAGNER, DENISE (MS, BS)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30141 ANTELOPE RD STE D726
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-7001
Mailing Address - Country:US
Mailing Address - Phone:196-318-6116
Mailing Address - Fax:
Practice Address - Street 1:29650 BRADLEY RD STE B
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92586-6521
Practice Address - Country:US
Practice Address - Phone:951-430-9247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37-8774OtherPROVIDER NUMBER