Provider Demographics
NPI:1063446409
Name:WAGNER, DEBRA SMITH (MSW)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:SMITH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12918 HAMLET AVE
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-9730
Mailing Address - Country:US
Mailing Address - Phone:952-454-3433
Mailing Address - Fax:
Practice Address - Street 1:MINNEAPOLIS VAMC-122
Practice Address - Street 2:ONE VETERANS DRIVE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417
Practice Address - Country:US
Practice Address - Phone:612-725-2042
Practice Address - Fax:612-725-2126
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN144701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical