Provider Demographics
NPI:1689723041
Name:WAGNER, ANNE S (LCSW)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:S
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 1:2622 PIONEER AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3402
Mailing Address - Country:US
Mailing Address - Phone:307-632-2240
Mailing Address - Fax:307-637-2899
Practice Address - Street 1:2622 PIONEER AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3024
Practice Address - Country:US
Practice Address - Phone:307-632-2240
Practice Address - Fax:307-637-2899
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY0721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY286867OtherVALUE OPTIONS
WY303435OtherBS OF WY
WYW10059OtherMEDICARE GROUP PIN
WY303435OtherBS OF WY