Provider Demographics
NPI:1295800951
Name:WAGNER, KAREN ELIZABETH (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:ELIZABETH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:ELIZABETH
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LSW
Mailing Address - Street 1:15 PATRIOTS PATH
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08880-1495
Mailing Address - Country:US
Mailing Address - Phone:215-378-6999
Mailing Address - Fax:
Practice Address - Street 1:127 UNION AVE STE 4
Practice Address - Street 2:
Practice Address - City:MIDDLESEX
Practice Address - State:NJ
Practice Address - Zip Code:08846-1039
Practice Address - Country:US
Practice Address - Phone:732-595-7689
Practice Address - Fax:732-595-3150
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05428000101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0023701Medicaid
NJ0023701Medicaid