Provider Demographics
NPI:1982763512
Name:WAGNER, AMY (LCSW-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4623 FALLS RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4914
Mailing Address - Country:US
Mailing Address - Phone:410-366-1980
Mailing Address - Fax:410-366-8530
Practice Address - Street 1:44 E GORDON ST
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-2916
Practice Address - Country:US
Practice Address - Phone:410-838-9000
Practice Address - Fax:410-838-8953
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD072761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD017189100Medicaid
MDKL86OtherBCBS
MD6214Medicare ID - Type Unspecified