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2324 University Ave W, Ste 100 St Paul MN 55114-1854 | |
| (651) 641-1009 | |
| (651) 789-5677 |
| Full Name | |
|---|---|
| Speciality | Psychologist |
| Location | 2324 University Ave W, Ste 100, St Paul, Minnesota |
| Authorized Official Name and Position | James Wagner (THERAPIST/PARTNER) |
| Authorized Official Contact | 6516411009 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
2324 University Ave W, Ste 100 St Paul MN 55114-1854 Ph: (651) 641-1009 | 2324 University Ave W, Ste 100 St Paul MN 55114-1854 Ph: (651) 641-1009 |
| NPI Number | 1568585420 |
|---|---|
| Provider Enumeration Date | 04/07/2007 |
| Last Update Date | 03/24/2023 |
| Certification Date | 03/24/2023 |
| Medicare PECOS PAC ID | 7214971191 |
|---|---|
| Medicare Enrollment ID | O20050613000043 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1568585420 | NPI | - | NPPES |
| 876248100 | Medicaid | MN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103T00000X | Psychologist | LP 3528 (Minnesota) | Primary |
| 103T00000X | Psychologist | LP 2149 (Minnesota) | Secondary |
| Provider Name | Debra L Klein |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1124179635 PECOS PAC ID: 0749224624 Enrollment ID: I20101021001476 |
| Provider Name | James Wagner |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1245740687 PECOS PAC ID: 8527593730 Enrollment ID: I20241211001483 |
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