Active NPI
Michael C Wagner, PSY.D
- Psychologist
- Frederick, MD
National Provider Identifier
1598045841
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- 05275
- Practice address
- 10 N Jefferson St
Suite 403
Frederick, MD 21701-3500 - Phone
- (301) 620-8700
- Fax
- (301) 620-8710
- NPI assigned
- Aug 18, 2011
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 05275 | MD | Primary |
| Clinical Psychologist | 103TC0700X | 0810004819 | VA |
Addresses
Primary practice location
10 N Jefferson St
Suite 403
Frederick, MD 21701-3500
Mailing address
10 N Jefferson St
Suite 403
Frederick, MD 21701-3500
Phone (301) 620-8700
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0810004819 | VA | MD | Clinical Psychologist |
| 05275 | MD | MD | Speech-Language Pathologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1313625600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1395705600000",
"number": "1598045841",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "10 N JEFFERSON ST",
"address_2": "SUITE 403",
"city": "FREDERICK",
"state": "MD",
"postal_code": "217013500",
"telephone_number": "301-620-8700",
"fax_number": "301-620-8710"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10 N JEFFERSON ST",
"address_2": "SUITE 403",
"city": "FREDERICK",
"state": "MD",
"postal_code": "217013500",
"telephone_number": "301-620-8700",
"fax_number": "301-620-8710"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNER",
"first_name": "MICHAEL",
"middle_name": "C",
"credential": "PSY.D",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2011-08-18",
"last_updated": "2014-03-25",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "MD",
"license": "05275",
"primary": true
},
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "VA",
"license": "0810004819",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Frederick, MD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.