Provider Demographics
NPI:1649415381
Name:WAGNER, MARLA R (MSW)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:R
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 STONE ABBEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-4616
Mailing Address - Country:US
Mailing Address - Phone:937-620-0706
Mailing Address - Fax:
Practice Address - Street 1:804 N HOAGLAND BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4518
Practice Address - Country:US
Practice Address - Phone:407-931-2911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health