Provider Demographics
NPI:1588729982
Name:WAGNER, GERALD T (LSCSW #2286)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:T
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LSCSW #2286
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 YOCEMENTO AVE
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-9678
Mailing Address - Country:US
Mailing Address - Phone:785-628-3726
Mailing Address - Fax:
Practice Address - Street 1:208 E 7TH
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-4199
Practice Address - Country:US
Practice Address - Phone:785-628-2871
Practice Address - Fax:785-628-1248
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW 22861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS069685OtherBCBS
KS069685Medicare ID - Type Unspecified