Provider Demographics
NPI:1164557500
Name:WAGER, DARYL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DARYL
Middle Name:
Last Name:WAGER
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 1:121 BIRCHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-3627
Mailing Address - Country:US
Mailing Address - Phone:631-732-0542
Mailing Address - Fax:
Practice Address - Street 1:405 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1651
Practice Address - Country:US
Practice Address - Phone:631-567-3320
Practice Address - Fax:631-567-3285
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2008-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072599-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY072599-1OtherLICENSE NUMBER
NY072599-1OtherLICENSE NUMBER