Provider Demographics
NPI:1134420185
Name:WAGNER, SUSAN CAROL (LSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:CAROL
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 DITHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-1503
Mailing Address - Country:US
Mailing Address - Phone:814-255-7907
Mailing Address - Fax:814-255-7907
Practice Address - Street 1:1108 DITHRIDGE DR
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-1503
Practice Address - Country:US
Practice Address - Phone:814-255-7907
Practice Address - Fax:814-255-7907
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW004045E104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker