Healthcare Provider Details

I. General information

NPI: 1588729982
Provider Name (Legal Business Name): GERALD T WAGNER LSCSW #2286
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 E 7TH
HAYS KS
67601-4199
US

IV. Provider business mailing address

2022 YOCEMENTO AVE
HAYS KS
67601-9678
US

V. Phone/Fax

Practice location:
  • Phone: 785-628-2871
  • Fax: 785-628-1248
Mailing address:
  • Phone: 785-628-3726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSCSW 2286
License Number StateKS

VII. Legacy identifiers

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

# 1
Identifier069685
Identifier TypeOTHER
Identifier StateKS
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: