Provider Demographics
NPI:1336432749
Name:WAGNER, TANYA (LCSW-C)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14502 GREENVIEW DR STE 550
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-3287
Mailing Address - Country:US
Mailing Address - Phone:301-825-1982
Mailing Address - Fax:443-279-2793
Practice Address - Street 1:14502 GREENVIEW DR STE 550
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-3287
Practice Address - Country:US
Practice Address - Phone:301-825-1982
Practice Address - Fax:443-279-2793
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD164131041C0700X, 104100000X
DCLC500799701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical