Healthcare Provider Details

I. General information

NPI: 1669801791
Provider Name (Legal Business Name): SAMANTHA WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

30 PROSPECT AVE
HACKENSACK NJ
07601-1914
US

V. Phone/Fax

Practice location:
  • Phone: 201-527-8663
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SL05714100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: