Provider Demographics
NPI:1356808455
Name:WAGNER, KELLY MCMAHON (LCSW-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MCMAHON
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:MCMAHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:4701 GREENSPRING AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4704
Mailing Address - Country:US
Mailing Address - Phone:443-642-2027
Mailing Address - Fax:
Practice Address - Street 1:4701 GREENSPRING AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-4704
Practice Address - Country:US
Practice Address - Phone:443-642-2027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD083291041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool