Provider Demographics
NPI:1669757043
Name:WAGNER, MARIA CATHERINE (LICSW)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:CATHERINE
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 1:3245 19TH ST NW
Mailing Address - Street 2:SUITE #1
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-7034
Mailing Address - Country:US
Mailing Address - Phone:507-208-4774
Mailing Address - Fax:
Practice Address - Street 1:3245 19TH STREET NW
Practice Address - Street 2:SUITE 1
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-6792
Practice Address - Country:US
Practice Address - Phone:507-208-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN188441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1336496207Medicaid
MN800003101OtherMEDICARE PTAN# (INDIVIDUAL)