Provider Demographics
NPI:1114240579
Name:NEIS-WAGNER, CANDACE JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:JEAN
Last Name:NEIS-WAGNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:JEAN
Other - Last Name:NEIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3040 N 117TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4128
Mailing Address - Country:US
Mailing Address - Phone:414-337-8988
Mailing Address - Fax:414-479-0230
Practice Address - Street 1:3040 N 117TH ST STE 100
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4128
Practice Address - Country:US
Practice Address - Phone:414-337-8988
Practice Address - Fax:414-479-0230
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7566-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical