Healthcare Provider Details

I. General information

NPI: 1578283370
Provider Name (Legal Business Name): JUSTIN WAGNER LLMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 02/01/2023
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 E NEWELL ST
WHITE CLOUD MI
49349-8795
US

IV. Provider business mailing address

1049 E NEWELL ST
WHITE CLOUD MI
49349-8795
US

V. Phone/Fax

Practice location:
  • Phone: 231-689-7330
  • Fax:
Mailing address:
  • Phone: 231-689-7330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851114971
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: