Healthcare Provider Details

I. General information

NPI: 1720132129
Provider Name (Legal Business Name): BETTY LOUISE WAGNER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 BIRMLEY ESTATES DR
TRAVERSE CITY MI
49696-8838
US

IV. Provider business mailing address

1028 BIRMLEY ESTATES DR
TRAVERSE CITY MI
49696-8838
US

V. Phone/Fax

Practice location:
  • Phone: 231-492-6529
  • Fax:
Mailing address:
  • Phone: 231-492-6529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL7525
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801081590
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: