Provider Demographics
NPI:1043594963
Name:WAGNER, WILLIAM DOUGLAS (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:DOUGLAS
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 PALM CT
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-5724
Mailing Address - Country:US
Mailing Address - Phone:859-979-0160
Mailing Address - Fax:
Practice Address - Street 1:2139 PALM CT
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-5724
Practice Address - Country:US
Practice Address - Phone:859-979-0160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW9961101YM0800X
KY356101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health