Provider Demographics
NPI:1437353976
Name:WAGNER, SUSAN FOLMAR (QMHP, MS)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:FOLMAR
Last Name:WAGNER
Suffix:
Gender:F
Credentials:QMHP, MS
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:F
Other - Last Name:MOSKOWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:QMHP, MS
Mailing Address - Street 1:1975 MCPHERSON ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-3482
Mailing Address - Country:US
Mailing Address - Phone:541-347-4940
Mailing Address - Fax:
Practice Address - Street 1:1040 ALLEGHENY AVE SW
Practice Address - Street 2:OCEAN CREST SCHOOL
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9034
Practice Address - Country:US
Practice Address - Phone:541-347-4940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YS0200X
CAMFC 15083106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist