Provider Demographics
NPI:1073077210
Name:WAGNER, GINNA THERESE (LCSW-C)
Entity Type:Individual
Prefix:
First Name:GINNA
Middle Name:THERESE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 LIGHT ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-4152
Mailing Address - Country:US
Mailing Address - Phone:667-600-2870
Mailing Address - Fax:667-600-4038
Practice Address - Street 1:1118 LIGHT ST STE 200
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-4152
Practice Address - Country:US
Practice Address - Phone:667-600-2870
Practice Address - Fax:667-600-4038
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD169871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical