Provider Demographics
NPI:1710688601
Name:WAGNER, NORTH (LMSW)
Entity Type:Individual
Prefix:
First Name:NORTH
Middle Name:
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 1:1191 NORTH AVE APT 309
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05408-2794
Mailing Address - Country:US
Mailing Address - Phone:409-444-5750
Mailing Address - Fax:
Practice Address - Street 1:278 MAIN ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-8336
Practice Address - Country:US
Practice Address - Phone:802-864-2651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT156.0133976104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker