Provider Demographics
NPI:1912551201
Name:WAGNER, JOAN M (PCSW, CAP, CAC, LMSW)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PCSW, CAP, CAC, LMSW
Other - Prefix:
Other - First Name:JOANIE
Other - Middle Name:
Other - Last Name:HINDS WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAC
Mailing Address - Street 1:54 KARA MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SUNDANCE
Mailing Address - State:WY
Mailing Address - Zip Code:82729-9583
Mailing Address - Country:US
Mailing Address - Phone:605-214-0316
Mailing Address - Fax:
Practice Address - Street 1:801 E 4TH ST STE 9
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4061
Practice Address - Country:US
Practice Address - Phone:307-257-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2025-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
IA118122104100000X
WYPCSW-10991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker