Provider Demographics
NPI:1639561699
Name:WAGNER, MARQUETTE (LSCSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MARQUETTE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LSCSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34314 W 255TH ST
Mailing Address - Street 2:
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-4215
Mailing Address - Country:US
Mailing Address - Phone:913-568-9639
Mailing Address - Fax:
Practice Address - Street 1:34314 W 255TH ST
Practice Address - Street 2:
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-4215
Practice Address - Country:US
Practice Address - Phone:913-568-9639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-28
Last Update Date:2015-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW 16051041C0700X
MO20130412521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical