Provider Demographics
NPI:1265121305
Name:WEGNER, JOSEPH (LMSW)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:WEGNER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8135 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-9428
Mailing Address - Country:US
Mailing Address - Phone:505-500-5294
Mailing Address - Fax:
Practice Address - Street 1:115 W WILDFLOWER DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-0100
Practice Address - Country:US
Practice Address - Phone:505-500-5294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-11283104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker