Provider Demographics
NPI:1427576842
Name:WILLIS-WAGNER, TRACI E (LISW)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:E
Last Name:WILLIS-WAGNER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2267 VILLAGE MALL DR
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OH
Mailing Address - Zip Code:44906-1369
Mailing Address - Country:US
Mailing Address - Phone:419-951-2020
Mailing Address - Fax:
Practice Address - Street 1:2267 VILLAGE MALL DR
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-1369
Practice Address - Country:US
Practice Address - Phone:419-951-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1700125104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker