Provider Demographics
NPI:1386775468
Name:WAGNER, TALIA MAYS (LMFT)
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:MAYS
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:864 S ROBERTSON BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1605
Mailing Address - Country:US
Mailing Address - Phone:310-425-5396
Mailing Address - Fax:
Practice Address - Street 1:864 S ROBERTSON BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1605
Practice Address - Country:US
Practice Address - Phone:310-425-5396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 46414106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist