Provider Demographics
NPI:1669019634
Name:WAGNER, HOLLAND VICTORIA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:HOLLAND
Middle Name:VICTORIA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 BROWNS LANE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401
Mailing Address - Country:US
Mailing Address - Phone:870-972-4939
Mailing Address - Fax:870-972-4911
Practice Address - Street 1:3700 ACCESS ROAD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
AR9614-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker