Provider Demographics
NPI:1053074575
Name:WAGNER, MARIE PIERRETTE
Entity Type:Individual
Prefix:MISS
First Name:MARIE
Middle Name:PIERRETTE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 NW 139TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168-2915
Mailing Address - Country:US
Mailing Address - Phone:513-607-4682
Mailing Address - Fax:
Practice Address - Street 1:326 NW 3RD STREET
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030
Practice Address - Country:US
Practice Address - Phone:786-779-8898
Practice Address - Fax:305-847-0432
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty