Healthcare Provider Details

I. General information

NPI: 1316433972
Provider Name (Legal Business Name): CHRISTINE MICHELLE WAGNER LSCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2018
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 E 21ST ST N
WICHITA KS
67214-2249
US

IV. Provider business mailing address

807 N WACO AVE STE 11
WICHITA KS
67203-3971
US

V. Phone/Fax

Practice location:
  • Phone: 316-691-0249
  • Fax: 866-514-0974
Mailing address:
  • Phone: 316-776-4360
  • Fax: 316-440-7054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number05354
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number05354
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: