Provider Demographics
NPI:1679858161
Name:WAGNER, GERRI LYNNE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GERRI
Middle Name:LYNNE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6312-1 WEST RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:NICHOLS
Mailing Address - State:NY
Mailing Address - Zip Code:13812
Mailing Address - Country:US
Mailing Address - Phone:607-259-1933
Mailing Address - Fax:
Practice Address - Street 1:459 PHILO ROAD
Practice Address - Street 2:GST BOCES
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14903
Practice Address - Country:US
Practice Address - Phone:607-739-3581
Practice Address - Fax:607-795-5305
Is Sole Proprietor?:No
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR041840101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool