Provider Demographics
NPI:1346080918
Name:WAGNER, MATTHEW (LSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 E ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2846
Mailing Address - Country:US
Mailing Address - Phone:717-393-3900
Mailing Address - Fax:717-393-7900
Practice Address - Street 1:41 E ORANGE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2846
Practice Address - Country:US
Practice Address - Phone:717-393-3900
Practice Address - Fax:717-393-7900
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW141420104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker