Provider Demographics
NPI:1417147984
Name:WAGNER, KATHLEEN J (LCSW, LMFT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 AVENUE D STE 2A
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-3015
Mailing Address - Country:US
Mailing Address - Phone:406-245-1338
Mailing Address - Fax:
Practice Address - Street 1:3021 6TH AVENUE NORTH
Practice Address - Street 2:SUITE 106
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-2223
Practice Address - Country:US
Practice Address - Phone:406-245-1338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT42106H00000X
MT7851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist