Provider Demographics
NPI:1831504901
Name:WAGNER, DENISE LOUISE (PSYD, LCSW)
Entity type:Individual
Prefix:DR
First Name:DENISE
Middle Name:LOUISE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PSYD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 10TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5291
Mailing Address - Country:US
Mailing Address - Phone:707-527-6000
Mailing Address - Fax:707-527-6111
Practice Address - Street 1:2055 CORTABELLA
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-8233
Practice Address - Country:US
Practice Address - Phone:575-545-3294
Practice Address - Fax:505-672-7769
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS172511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical