MEDICARE: MRS. ANNE M WAGNER LSW

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	104100000X	Social Worker	LS10780	ME

General Provider Information

NPI Number	:	1770602096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANNE M WAGNER LSW

Provider Business Mailing Address
First Line	:	PO BOX 16
Second Line	:
City	:	CORINNA
State	:	ME
Zip	:	04928-0016
Country	:	US
Telephone Number	:	207-278-7630
Fax Number	:

Provider Business Practice Location Address
First Line	:	98 MAIN ST
Second Line	:
City	:	SKOWHEGAN
State	:	ME
Zip	:	04976-1146
Country	:	US
Telephone Number	:	207-858-0067
Fax Number	:

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

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	07/08/2007

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