Provider Demographics
NPI:1508477134
Name:WAGNER, REBECCA (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
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 1:521 N ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4128
Mailing Address - Country:US
Mailing Address - Phone:406-426-1486
Mailing Address - Fax:
Practice Address - Street 1:521 N ORANGE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4128
Practice Address - Country:US
Practice Address - Phone:406-426-1487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical