Healthcare Provider Details

I. General information

NPI: 1902731128
Provider Name (Legal Business Name): TAMBERLY KAY WAGNER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 4TH AVE E
POLSON MT
59860-2117
US

IV. Provider business mailing address

48833 CROW DAM RD
RONAN MT
59864-9223
US

V. Phone/Fax

Practice location:
  • Phone: 406-883-5541
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-88188
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: