Provider Demographics
NPI:1902294325
Name:WAGNER, TIFFANY (LCSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-6421
Mailing Address - Country:US
Mailing Address - Phone:610-326-9250
Mailing Address - Fax:
Practice Address - Street 1:640 WALNUT ST
Practice Address - Street 2:SUITE 303
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19601
Practice Address - Country:US
Practice Address - Phone:610-208-8860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0199491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical