1497059935 NPI number — CENTER FOR INTEGRATIVE PSYCHOLOGY & WELLNESS INC

Table of content: BARRY MICHAEL WAGNER PH.D. (NPI 1285652842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497059935 NPI number — CENTER FOR INTEGRATIVE PSYCHOLOGY & WELLNESS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR INTEGRATIVE PSYCHOLOGY & WELLNESS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497059935
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1932
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANFORD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93232-1932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1040 MAIN ST
Provider Second Line Business Practice Location Address:
#305
Provider Business Practice Location Address City Name:
NAPA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94559-2654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-253-9115
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DECARVALHO
Authorized Official First Name:
LORIE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
FOUNDER AND PRESIDENT/CEO
Authorized Official Telephone Number:
707-253-9115

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY20053 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1366480915 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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