Provider Demographics
NPI:1609801984
Name:WAGNER, CINDY J (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CINDY
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:CINDY
Other - Middle Name:J
Other - Last Name:BRINKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:258 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122
Mailing Address - Country:US
Mailing Address - Phone:317-718-0605
Mailing Address - Fax:317-718-0720
Practice Address - Street 1:258 MEADOW DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122
Practice Address - Country:US
Practice Address - Phone:317-718-0605
Practice Address - Fax:317-718-0720
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003577A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
11487765OtherCAQH
000000378933OtherANTHEM BCBS
000000378933OtherANTHEM BCBS