Provider Demographics
NPI:1972588606
Name:WAGNER, LINDA M (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:M
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 1:1801 WATERMARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-7088
Mailing Address - Country:US
Mailing Address - Phone:614-487-8758
Mailing Address - Fax:614-227-9447
Practice Address - Street 1:4055 FABER PLACE DR STE 300
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8524
Practice Address - Country:US
Practice Address - Phone:614-487-8758
Practice Address - Fax:614-227-9447
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA095666Medicare ID - Type Unspecified