Provider Demographics
NPI:1336804707
Name:WAGNER, KARI (LMSW-CC)
Entity Type:Individual
Prefix:
First Name:KARI
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MALLISON ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-5845
Mailing Address - Country:US
Mailing Address - Phone:207-415-2591
Mailing Address - Fax:
Practice Address - Street 1:10 MALLISON ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-5845
Practice Address - Country:US
Practice Address - Phone:207-415-2591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC40671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical