Individual
MRS. KASSIDY DIANE WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
BCBA
Contact information
Practice address
449 S FITNESS PL, EAGLE, ID 83616-6828
(208) 957-6301
(208) 228-0585
Mailing address
449 S FITNESS PL, EAGLE, ID 83616-6828
(208) 957-6301
(208) 228-0585
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
1-23-68300
ID
Other
Enumeration date
07/24/2019
Last updated
12/21/2023
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