Provider Demographics
NPI:1336816271
Name:WAGNER, MARISA (IMFT)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:IMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9104 STATE ROUTE 108
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-9526
Mailing Address - Country:US
Mailing Address - Phone:419-388-6663
Mailing Address - Fax:
Practice Address - Street 1:22251 STATE ROUTE 2
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-9452
Practice Address - Country:US
Practice Address - Phone:419-445-1552
Practice Address - Fax:419-445-1401
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHM.2100239-TRNE101YM0800X
OHF.2400426101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHM.2100239-TRNEOtherOHIO COUNSELOR, SOCIAL WORKER, AND MARRIAGE AND FAMILY THERAPY BOARD