Provider Demographics
NPI:1598537284
Name:WAGNER, KATHARINE KUBALL (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHARINE
Middle Name:KUBALL
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 1:145 N CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2906
Mailing Address - Country:US
Mailing Address - Phone:773-680-1775
Mailing Address - Fax:
Practice Address - Street 1:5017 W BERTEAU AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1738
Practice Address - Country:US
Practice Address - Phone:630-865-1352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0131211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical