Provider Demographics
NPI:1356909691
Name:WAGNER, ERIN MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:MARIE
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 1:1626 COMMONWEALTH AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-5027
Mailing Address - Country:US
Mailing Address - Phone:386-785-9431
Mailing Address - Fax:
Practice Address - Street 1:41 GARRISON RD
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-4445
Practice Address - Country:US
Practice Address - Phone:617-277-8107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0002266911041C0700X
390200000X
MA1264211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program