Provider Demographics
NPI:1083851075
Name:WAGENKNECHT, CANDICE (PLCSW)
Entity Type:Individual
Prefix:MS
First Name:CANDICE
Middle Name:
Last Name:WAGENKNECHT
Suffix:
Gender:F
Credentials:PLCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S LIMIT AVE
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-3655
Mailing Address - Country:US
Mailing Address - Phone:660-826-7909
Mailing Address - Fax:660-826-6737
Practice Address - Street 1:100 S LIMIT AVE
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-3655
Practice Address - Country:US
Practice Address - Phone:660-826-7909
Practice Address - Fax:660-826-6737
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080369111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical