Provider Demographics
NPI:1295992907
Name:WAGNER, LYNNETTE YVONNE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:LYNNETTE
Middle Name:YVONNE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18101 HARTLEY DR
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-7915
Mailing Address - Country:US
Mailing Address - Phone:218-828-4611
Mailing Address - Fax:218-828-4611
Practice Address - Street 1:18101 HARTLEY DR
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-7915
Practice Address - Country:US
Practice Address - Phone:218-828-4611
Practice Address - Fax:218-828-4611
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical