=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316433972
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE MICHELLE WAGNER LSCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2018
-----------------------------------------------------
Last Update Date | 04/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2707 E 21ST ST N
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67214-2249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-691-0249
-----------------------------------------------------
Fax | 866-514-0974
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 807 N WACO AVE STE 11
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67203-3971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-776-4360
-----------------------------------------------------
Fax | 316-440-7054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 05354
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 05354
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------