Provider Demographics
NPI:1477936425
Name:WAGNER, LINDA (LCSW)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:M
Other - Last Name:KICSAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1062 STATE ROUTE 38
Mailing Address - Street 2:
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-3209
Mailing Address - Country:US
Mailing Address - Phone:607-687-4000
Mailing Address - Fax:
Practice Address - Street 1:1062 STATE ROUTE 38
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-3209
Practice Address - Country:US
Practice Address - Phone:321-326-0839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW13683101Y00000X, 1041C0700X
NYR078023-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW13683OtherFLORIDA DOH
NYR078023-01OtherLCSW R