Provider Demographics
NPI:1770082828
Name:WAGNER, MACKENZIE TAYLOR (LLBSW)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:TAYLOR
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 40TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-6084
Mailing Address - Country:US
Mailing Address - Phone:616-426-7848
Mailing Address - Fax:
Practice Address - Street 1:1111 40TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-6084
Practice Address - Country:US
Practice Address - Phone:616-426-7848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker