Provider Demographics
NPI:1235427311
Name:WAGNER, LAURA J (MSW LICSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MECHANIC ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-4425
Mailing Address - Country:US
Mailing Address - Phone:508-308-9261
Mailing Address - Fax:508-449-3972
Practice Address - Street 1:40 MECHANIC ST
Practice Address - Street 2:SUITE 306
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-4425
Practice Address - Country:US
Practice Address - Phone:508-308-9261
Practice Address - Fax:508-449-3972
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1158571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0024010OtherMEDICARE PTAN