Provider Demographics
NPI:1336271477
Name:WAGNER, TERESA LEE (MSW)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LEE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W NORTHVIEW RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-6041
Mailing Address - Country:US
Mailing Address - Phone:607-273-6767
Mailing Address - Fax:
Practice Address - Street 1:215 N GENEVA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4135
Practice Address - Country:US
Practice Address - Phone:607-227-1026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR042129-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY566791OtherVALUE OPTIONS