Provider Demographics
NPI:1629182225
Name:WAGNER, LISA ELIZABETH (LISW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ELIZABETH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4332
Mailing Address - Country:US
Mailing Address - Phone:419-221-3072
Mailing Address - Fax:
Practice Address - Street 1:405 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KENTON
Practice Address - State:OH
Practice Address - Zip Code:43326-1375
Practice Address - Country:US
Practice Address - Phone:419-679-5994
Practice Address - Fax:419-225-8878
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00096751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical