Active NPI
Audrey Wagner, PH.D.
- Clinical Psychologist
- Watertown, MA
National Provider Identifier
1922047679
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 4685
- Practice address
- 173 Mount Auburn St
Watertown, MA 02472-4005 - Phone
- (617) 923-2468
- NPI assigned
- Jun 6, 2006
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 4685 | MA | Primary |
Addresses
Primary practice location
173 Mount Auburn St
Watertown, MA 02472-4005
Mailing address
173 Mount Auburn St
Watertown, MA 02472-4005
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| W04524 | Other | MA | BCBS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective May 1, 2020 through May 1, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1149552000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1922047679",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "173 MOUNT AUBURN ST",
"city": "WATERTOWN",
"state": "MA",
"postal_code": "024724005"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "173 MOUNT AUBURN ST",
"city": "WATERTOWN",
"state": "MA",
"postal_code": "024724005",
"telephone_number": "617-923-2468"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNER",
"first_name": "AUDREY",
"credential": "PH.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2006-06-06",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MA",
"license": "4685",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "W04524",
"state": "MA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Watertown, MA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.