Provider Demographics
NPI:1396756243
Name:WAGNER, RICHARD PAUL (LCSW)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:PAUL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:T-9 FORT MISSOULA
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7202
Mailing Address - Country:US
Mailing Address - Phone:406-532-8400
Mailing Address - Fax:
Practice Address - Street 1:106 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-9224
Practice Address - Country:US
Practice Address - Phone:406-723-5489
Practice Address - Fax:406-782-4020
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000005508Medicare PIN