Provider Demographics
NPI:1154584217
Name:WAGNER, KARL FREDERIC (PSYD)
Entity type:Individual
Prefix:DR
First Name:KARL
Middle Name:FREDERIC
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 84
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3067
Mailing Address - Country:US
Mailing Address - Phone:617-494-1650
Mailing Address - Fax:617-494-1975
Practice Address - Street 1:875 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 84
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3067
Practice Address - Country:US
Practice Address - Phone:617-494-1650
Practice Address - Fax:617-494-1975
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7443103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical