Individual
REBECCA WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PH.D.
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
1139
SC
103TC0700X
Clinical Psychologist
Primary
PSY.0005316
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
PS0478
—
SC
Enumeration date
01/23/2007
Last updated
07/10/2023
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