Provider Demographics
NPI:1962137711
Name:WAGNER, MARGOT
Entity type:Individual
Prefix:MISS
First Name:MARGOT
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MILLER DR STE 104
Mailing Address - Street 2:
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-5144
Mailing Address - Country:US
Mailing Address - Phone:630-587-3777
Mailing Address - Fax:
Practice Address - Street 1:66 MILLER DR STE 104
Practice Address - Street 2:
Practice Address - City:NORTH AURORA
Practice Address - State:IL
Practice Address - Zip Code:60542-5144
Practice Address - Country:US
Practice Address - Phone:630-587-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-17
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.108357104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty