Provider Demographics
NPI:1467905679
Name:WAGNER, URSULA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:URSULA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 E 59TH ST
Mailing Address - Street 2:APT. A0
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-2009
Mailing Address - Country:US
Mailing Address - Phone:217-649-9376
Mailing Address - Fax:
Practice Address - Street 1:1015 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5017
Practice Address - Country:US
Practice Address - Phone:312-350-3257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0162951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical