Provider Demographics
NPI:1649813973
Name:WAGNER, JOHN EDWARD (LSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-1832
Mailing Address - Country:US
Mailing Address - Phone:973-773-7600
Mailing Address - Fax:973-773-7011
Practice Address - Street 1:53 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1832
Practice Address - Country:US
Practice Address - Phone:973-773-7600
Practice Address - Fax:973-773-7011
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06420400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker