Basic Information
| Provider Information | |||||||||
| NPI: | 1194261032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 GLENWOOD ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074448293 | ||||||||
| FaxNumber: | 7074448298 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 GLENWOOD ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074448293 | ||||||||
| FaxNumber: | 7074448298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2017 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | IMF100236 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 106H00000X | 126197 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.