Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 23806 | CA |
Y | 103TC0700X | Clinical Psychologist | 23806 | CA |
N | 102L00000X | Psychologist | 23806 | CA |
N | 103T00000X | Psychologist | 23806 | CA |
N | 103G00000X | Clinical Psychologist | 23806 | CA |
N | 103TC0700X | Clinical Psychologist | 23806 | CA |
N | 103TR0400X | Rehabilitation Psychologist | 23806 | CA |
NPI | 1417168642 |
---|---|
Provider Name | John Wager |
First Address | Mountain View, CA 94040-4101 |
Second Address | Mountain View, CA 94040-4101 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/05/2007 |
Last Update Date | 11/11/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
46-3467093 | TAX IDENTIFICATION (01) | CA |