Provider Demographics
NPI:1184928962
Name:WAGNER, MARK H (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:75 NEW SCOTLAND AVE
Mailing Address - Street 2:CDPC - CHILD AND ADOLESCENT SERVICE
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3409
Mailing Address - Country:US
Mailing Address - Phone:518-447-9647
Mailing Address - Fax:518-426-2902
Practice Address - Street 1:75 NEW SCOTLAND AVE
Practice Address - Street 2:CDPC - CHILD AND ADOLESCENT SERVICE
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3409
Practice Address - Country:US
Practice Address - Phone:518-447-9647
Practice Address - Fax:518-426-2902
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018860103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist