MEDICARE: MR. KYLE WILLIAM WAGNER MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	ISW17580	FL

General Provider Information

NPI Number	:	1184351751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KYLE WILLIAM WAGNER MSW

Provider Business Mailing Address
First Line	:	1104 SANDALWOOD CIR
Second Line	:
City	:	NICEVILLE
State	:	FL
Zip	:	32578-4213
Country	:	US
Telephone Number	:	850-889-0773
Fax Number	:

Provider Business Practice Location Address
First Line	:	327 S COUNTY HIGHWAY 393 UNIT 201
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-8209
Country	:	US
Telephone Number	:	850-889-0773
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2022
Last Update Date	:	08/04/2022

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