Provider Demographics
NPI:1285834499
Name:WAGNER, KIMBERLY JEAN GOLDING (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JEAN GOLDING
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:JEAN
Other - Last Name:GOLDING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1519 NYE ROAD
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489
Mailing Address - Country:US
Mailing Address - Phone:315-946-5722
Mailing Address - Fax:315-946-5726
Practice Address - Street 1:1519 NYE ROAD
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489
Practice Address - Country:US
Practice Address - Phone:315-946-5722
Practice Address - Fax:315-946-5726
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073383104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00357502Medicaid