Provider Demographics
NPI:1013714005
Name:WAGNER, STEPHANIE ERIN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ERIN
Last Name:WAGNER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11666 TIMBERLANE TRL
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48353-3455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:808 W LAKE LANSING RD STE 200
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6322
Practice Address - Country:US
Practice Address - Phone:517-416-1790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511195511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical