Provider Demographics
NPI:1407008147
Name:WAGNER, THOMAS C (LCSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:C
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 W SAHARA AVE
Mailing Address - Street 2:SUITE #104
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-0353
Mailing Address - Country:US
Mailing Address - Phone:702-248-6290
Mailing Address - Fax:702-248-4720
Practice Address - Street 1:5300 W SAHARA AVE
Practice Address - Street 2:SUITE #104
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-0353
Practice Address - Country:US
Practice Address - Phone:702-248-6290
Practice Address - Fax:702-248-4720
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01761-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical