Provider Demographics
NPI:1346754702
Name:WAGNER, IVY CHRISTINE (CSWA)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:CHRISTINE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 BLUFF AVE SW
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-9614
Mailing Address - Country:US
Mailing Address - Phone:503-984-9243
Mailing Address - Fax:
Practice Address - Street 1:1125 ALABAMA AVE SE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9105
Practice Address - Country:US
Practice Address - Phone:541-329-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10286104100000X
ORA12011104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker