Provider Demographics
NPI:1497827828
Name:VAN WAGNER, ERICA WESTHART (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:WESTHART
Last Name:VAN WAGNER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 LINDA LANE
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-9495
Mailing Address - Country:US
Mailing Address - Phone:803-238-7369
Mailing Address - Fax:
Practice Address - Street 1:124 MALLARD ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601
Practice Address - Country:US
Practice Address - Phone:864-241-1040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid
SC301100Medicaid