Provider Demographics
NPI:1952690265
Name:WAGNER, WILLIAM RICHARD (MSW, APSW)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RICHARD
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MSW, APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 7TH ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1222
Mailing Address - Country:US
Mailing Address - Phone:262-634-2391
Mailing Address - Fax:262-634-5342
Practice Address - Street 1:420 7TH ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1222
Practice Address - Country:US
Practice Address - Phone:262-634-2391
Practice Address - Fax:262-634-5342
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI127915-121104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical