| NPI | 1952777575 |
|---|---|
| Former Name | BREA-ANNE WAGNER |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: OH P.07840) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: IN 20043030A) |
| Enumeration Date | 2015-08-18 |
| Last Update Date | 2019-01-09 |