Provider Demographics
NPI:1174877161
Name:ALBANES-WAGNER, MAURICE
Entity type:Individual
Prefix:
First Name:MAURICE
Middle Name:
Last Name:ALBANES-WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 MORENA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3850
Mailing Address - Country:US
Mailing Address - Phone:619-398-0355
Mailing Address - Fax:
Practice Address - Street 1:9808 VENICE BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2732
Practice Address - Country:US
Practice Address - Phone:310-945-3350
Practice Address - Fax:310-840-7023
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA799937163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health