Healthcare Provider Details

I. General information

NPI: 1063340164
Provider Name (Legal Business Name): EMILY BRIANNE WAGNER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 E 1ST N
REXBURG ID
83440-1505
US

IV. Provider business mailing address

58 E 1ST N
REXBURG ID
83440-1505
US

V. Phone/Fax

Practice location:
  • Phone: 208-671-0985
  • Fax:
Mailing address:
  • Phone: 208-671-0985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-42205
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: