Healthcare Provider Details

I. General information

NPI: 1336694637
Provider Name (Legal Business Name): MARY KATHERINE WANNER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 DAWSON RD STE 101
ALBANY GA
31707-1326
US

IV. Provider business mailing address

PO BOX 1988
ALBANY GA
31702-1988
US

V. Phone/Fax

Practice location:
  • Phone: 229-430-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003991
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: