Provider Demographics
NPI:1497828156
Name:WAGNER, MARYSA C (MSE)
Entity Type:Individual
Prefix:
First Name:MARYSA
Middle Name:C
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S 13TH ST
Mailing Address - Street 2:STE A
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-4968
Mailing Address - Country:US
Mailing Address - Phone:402-371-5632
Mailing Address - Fax:402-371-5632
Practice Address - Street 1:601 S 13TH ST
Practice Address - Street 2:STE A
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-4968
Practice Address - Country:US
Practice Address - Phone:402-371-5632
Practice Address - Fax:402-371-5632
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2125101YM0800X
NE1208101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47083406326Medicaid
NE470834063Medicare UPIN