Healthcare Provider Details

I. General information

NPI: 1578467106
Provider Name (Legal Business Name): CHRISTINE B. WAGNER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 BLACKSTONE VALLEY PL STE 2
LINCOLN RI
02865-1182
US

IV. Provider business mailing address

594 VICTORY HWY
MAPLEVILLE RI
02839-1256
US

V. Phone/Fax

Practice location:
  • Phone: 401-475-0653
  • Fax: 401-475-0729
Mailing address:
  • Phone: 401-332-0378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW04992
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: