Provider Demographics
NPI:1952468936
Name:WAGNER, ALLEN (MS)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 22ND ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5046
Mailing Address - Country:US
Mailing Address - Phone:608-782-4575
Mailing Address - Fax:
Practice Address - Street 1:421 22ND ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5046
Practice Address - Country:US
Practice Address - Phone:608-782-4575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI869-125101YP2500X
WI32141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical