Provider Demographics
NPI:1760537062
Name:WAGNER, CAROL THERESA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:THERESA
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 1:286 LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-3334
Mailing Address - Country:US
Mailing Address - Phone:718-892-7599
Mailing Address - Fax:718-892-3970
Practice Address - Street 1:2780 SCHURZ AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-3234
Practice Address - Country:US
Practice Address - Phone:718-863-9134
Practice Address - Fax:718-863-6125
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP1600X, 101YS0200X, 104100000X, 1041S0200X, 106H00000X
NYPR029268-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
147324OtherVALUE OPTIONS
147324OtherVALUE OPTIONS