Provider Demographics
NPI:1366652182
Name:WAGNER, HEIDI RENEE' (ATR-BC, LSW)
Entity Type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:RENEE'
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ATR-BC, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 HILLSDOWNE RD
Mailing Address - Street 2:APT. D
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-3322
Mailing Address - Country:US
Mailing Address - Phone:614-542-9089
Mailing Address - Fax:
Practice Address - Street 1:675 HILLSDOWNE RD
Practice Address - Street 2:APT. D
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-3322
Practice Address - Country:US
Practice Address - Phone:614-542-9089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS-0018147104100000X
OH94-160,CERTIFICATION221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist