Provider Demographics
NPI:1962179804
Name:WAGNER PSYCHOTHERAPY LLC
Entity type:Organization
Organization Name:WAGNER PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:703-646-1518
Mailing Address - Street 1:10911 ADARE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-3105
Mailing Address - Country:US
Mailing Address - Phone:703-646-1518
Mailing Address - Fax:
Practice Address - Street 1:8280 WILLOW OAKS CORPORATE DRIVE
Practice Address - Street 2:SUITE 600 - #5752
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4516
Practice Address - Country:US
Practice Address - Phone:703-646-1518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty