Provider Demographics
NPI:1083489173
Name:WAGNER, AMIE E (LCSW)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 STONEFIELD PL
Mailing Address - Street 2:
Mailing Address - City:HONEOYE FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14472-1158
Mailing Address - Country:US
Mailing Address - Phone:585-703-1904
Mailing Address - Fax:
Practice Address - Street 1:23 STONEFIELD PL
Practice Address - Street 2:
Practice Address - City:HONEOYE FALLS
Practice Address - State:NY
Practice Address - Zip Code:14472-1158
Practice Address - Country:US
Practice Address - Phone:585-703-1904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0647171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical