Provider Demographics
NPI:1932551728
Name:WAGAR, SUSAN KIM (LSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KIM
Last Name:WAGAR
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 CHERRY LANE RD
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-8298
Mailing Address - Country:US
Mailing Address - Phone:518-653-9684
Mailing Address - Fax:
Practice Address - Street 1:760 CHERRY LANE RD
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-8298
Practice Address - Country:US
Practice Address - Phone:518-653-9684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW133565101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health