Healthcare Provider Details

I. General information

NPI: 1952690265
Provider Name (Legal Business Name): WILLIAM RICHARD WAGNER M.S.W., A.P.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 7TH ST
RACINE WI
53403-1222
US

IV. Provider business mailing address

420 7TH ST
RACINE WI
53403-1222
US

V. Phone/Fax

Practice location:
  • Phone: 262-634-2391
  • Fax: 262-634-5342
Mailing address:
  • Phone: 262-634-2391
  • Fax: 262-634-5342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number127915-121
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number127915-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: