Provider Demographics
NPI:1457126906
Name:WAGNER, CARLY (BSW)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5343
Mailing Address - Country:US
Mailing Address - Phone:304-748-3768
Mailing Address - Fax:
Practice Address - Street 1:3920 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5343
Practice Address - Country:US
Practice Address - Phone:304-748-3768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator