Provider Demographics
NPI:1245358597
Name:WAGNER, CORTNEY PAIGE (MFT)
Entity type:Individual
Prefix:MRS
First Name:CORTNEY
Middle Name:PAIGE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11555 LOS OSOS VALLEY RD STE 210
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-6417
Mailing Address - Country:US
Mailing Address - Phone:805-334-0863
Mailing Address - Fax:
Practice Address - Street 1:11555 LOS OSOS VALLEY RD STE 210
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-6417
Practice Address - Country:US
Practice Address - Phone:805-334-0863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC43797106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist