MEDICARE: KATHLEEN J. WAGNER LCSW, LMFT

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	106H00000X	Marriage & Family Therapist	42	MT
2	1041C0700X	Clinical Social Worker	785	MT

General Provider Information

NPI Number	:	1417147984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN J. WAGNER LCSW, LMFT

Provider Business Mailing Address
First Line	:	1629 AVENUE D STE 2A
Second Line	:
City	:	BILLINGS
State	:	MT
Zip	:	59102-3015
Country	:	US
Telephone Number	:	406-245-1338
Fax Number	:

Provider Business Practice Location Address
First Line	:	3021 6TH AVENUE NORTH
Second Line	:	SUITE 106
City	:	BILLINGS
State	:	MT
Zip	:	59101-2223
Country	:	US
Telephone Number	:	406-245-1338
Fax Number	:

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

Provider Enumeration Date	:	07/30/2007
Last Update Date	:	06/18/2020

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