Provider Demographics
NPI:1154961019
Name:DYMOND WAGNER, MARILYN SUE
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:SUE
Last Name:DYMOND WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 OVERLAND TRL STE 10582601
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-1318
Mailing Address - Country:US
Mailing Address - Phone:307-333-1123
Mailing Address - Fax:
Practice Address - Street 1:777 OVERLAND TRL STE 10582601
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1318
Practice Address - Country:US
Practice Address - Phone:307-333-1123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical