| Wagner Psychotherapy Llc | |
|
8280 Willow Oaks Corporate Drive Suite 600 - #5752 Fairfax VA 22031-4516 | |
| (703) 646-1518 | |
| Not Available |
| Full Name | Wagner Psychotherapy Llc |
|---|---|
| Speciality | Psychologist |
| Location | 8280 Willow Oaks Corporate Drive, Fairfax, Virginia |
| Authorized Official Name and Position | Diane Wagner (OWNER) |
| Authorized Official Contact | 7036461518 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Wagner Psychotherapy Llc 10911 Adare Dr Fairfax VA 22032-3105 Ph: (703) 646-1518 | Wagner Psychotherapy Llc 8280 Willow Oaks Corporate Drive Suite 600 - #5752 Fairfax VA 22031-4516 Ph: (703) 646-1518 |
| NPI Number | 1962179804 |
|---|---|
| Provider Enumeration Date | 08/27/2021 |
| Last Update Date | 08/27/2021 |
| Certification Date | 08/27/2021 |
| Medicare PECOS PAC ID | 0749686871 |
|---|---|
| Medicare Enrollment ID | O20210914003914 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1962179804 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | (* (Not Available)) | Primary |
| Provider Name | Diane C Wagner |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1194211540 PECOS PAC ID: 9830448844 Enrollment ID: I20180824001661 |
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