Provider Demographics
NPI:1295863215
Name:WAGNER, NANCY ELIZABETH (MSW LCSW LISAC)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ELIZABETH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSW LCSW LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10204 BODE ST STE B
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-9813
Mailing Address - Country:US
Mailing Address - Phone:855-241-7160
Mailing Address - Fax:954-324-8354
Practice Address - Street 1:2408 E PECOS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-8272
Practice Address - Country:US
Practice Address - Phone:480-329-9688
Practice Address - Fax:480-329-9688
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11062101YA0400X
AZLCSW-115341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)