Provider Demographics
NPI:1821191834
Name:WAGNER, MEGAN J (LCSW)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:J
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 1:207 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-6995
Mailing Address - Country:US
Mailing Address - Phone:573-421-2065
Mailing Address - Fax:
Practice Address - Street 1:207 PRIMROSE LN
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-6995
Practice Address - Country:US
Practice Address - Phone:573-421-2065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040244361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical