Provider Demographics
NPI:1871113316
Name:WAGNER, SCOTT D I
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:D
Last Name:WAGNER
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 E TABOR AVE APT 15319
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3955
Mailing Address - Country:US
Mailing Address - Phone:510-372-3757
Mailing Address - Fax:
Practice Address - Street 1:319 E TABOR AVE APT 15319
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3955
Practice Address - Country:US
Practice Address - Phone:510-372-3757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor