Provider Demographics
NPI:1861385874
Name:WAGNER, MATHEW (MA PPS)
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MA PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 ALTO DR
Mailing Address - Street 2:
Mailing Address - City:OAK VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:93022-9526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 LAUREL RD
Practice Address - Street 2:
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060-1133
Practice Address - Country:US
Practice Address - Phone:805-933-8951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool