Provider Demographics
NPI:1902442163
Name:WAGNER, KATELYN (LISW)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:
Other - Last Name:STRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:PO BOX 1345
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43086-7345
Mailing Address - Country:US
Mailing Address - Phone:614-285-4827
Mailing Address - Fax:
Practice Address - Street 1:4449 EASTON WAY # FI2
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-6093
Practice Address - Country:US
Practice Address - Phone:614-285-4827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-22
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2004925104100000X, 1041C0700X
OHS.2009251041C0700X
OH390200000X
OHI.23045201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid