Provider Demographics
NPI:1386120731
Name:WAGNER, STEPHANIE (LCSW, LISW-CP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 OLDECASTLE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-8404
Mailing Address - Country:US
Mailing Address - Phone:980-272-8561
Mailing Address - Fax:
Practice Address - Street 1:6815 OLDECASTLE CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-8404
Practice Address - Country:US
Practice Address - Phone:980-272-8561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC118331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical