Provider Demographics
NPI:1649782574
Name:WAGNER, ALICIA ANN (LIMHP, LCSW, LADC)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LIMHP, LCSW, LADC
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:ANN
Other - Last Name:HOLDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHP, MSW
Mailing Address - Street 1:1909 VICKI LN STE 105
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-4542
Mailing Address - Country:US
Mailing Address - Phone:402-256-7883
Mailing Address - Fax:
Practice Address - Street 1:1909 VICKI LN STE 105
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-4542
Practice Address - Country:US
Practice Address - Phone:402-256-7883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2023-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4490101YM0800X
NE15561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10028558800Medicaid