Provider Demographics
NPI:1437751138
Name:WAGNER, LINDSEY JOANN (SACIT)
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:JOANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:SACIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2119
Mailing Address - Country:US
Mailing Address - Phone:920-887-1766
Mailing Address - Fax:
Practice Address - Street 1:115 N CENTER ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2119
Practice Address - Country:US
Practice Address - Phone:920-887-1766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18986101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)