Healthcare Provider Details

I. General information

NPI: 1336926393
Provider Name (Legal Business Name): BRIAN JOSEPH WAGNER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E LOOP RD STE 301
WHEATON IL
60189-1938
US

IV. Provider business mailing address

55 E LOOP RD STE 301
WHEATON IL
60189-1938
US

V. Phone/Fax

Practice location:
  • Phone: 630-428-7890
  • Fax: 630-428-7891
Mailing address:
  • Phone: 630-428-7890
  • Fax: 630-428-7891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149025667
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: