Provider Demographics
NPI:1225240922
Name:WAGNER, MOLLY MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:MARIE
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 1:522 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-1462
Mailing Address - Country:US
Mailing Address - Phone:814-516-2744
Mailing Address - Fax:
Practice Address - Street 1:1001 STATE ST STE 102
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1835
Practice Address - Country:US
Practice Address - Phone:814-580-1743
Practice Address - Fax:814-240-6347
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0156481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical