Provider Demographics
NPI:1720134216
Name:WAGNER, STEVEN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5210 E PIMA ST STE 105
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-3693
Mailing Address - Country:US
Mailing Address - Phone:520-629-9166
Mailing Address - Fax:520-795-3575
Practice Address - Street 1:5210 E PIMA ST STE 105
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-3693
Practice Address - Country:US
Practice Address - Phone:520-629-9166
Practice Address - Fax:520-795-3575
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-2967101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ734732Medicaid
AZ734732Medicaid
AZ28864Medicare ID - Type Unspecified