Provider Demographics
NPI:1104655877
Name:WAGNER, BRITTANY MICHELLE
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:MICHELLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRITTANY
Other - Middle Name:MICHELLE
Other - Last Name:EMBREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20301 PIMA RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-5124
Mailing Address - Country:US
Mailing Address - Phone:760-267-6767
Mailing Address - Fax:
Practice Address - Street 1:16552 SUNHILL DR
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4518
Practice Address - Country:US
Practice Address - Phone:760-780-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC16453101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health