Provider Demographics
NPI:1366044778
Name:WAGNER, CHRISTOPHER ROBERT
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:ROBERT
Last Name: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 1:55865 EL DORADO DR
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-3535
Mailing Address - Country:US
Mailing Address - Phone:760-861-8982
Mailing Address - Fax:
Practice Address - Street 1:55865 EL DORADO DR
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-3535
Practice Address - Country:US
Practice Address - Phone:760-620-5554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA154300106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist