Provider Demographics
NPI:1538780077
Name:WAGNER, SHANNON MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
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 1:2310 E ATLANTIC BLVD BLDG 2
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-5251
Mailing Address - Country:US
Mailing Address - Phone:954-990-7171
Mailing Address - Fax:954-530-5992
Practice Address - Street 1:2310 E ATLANTIC BLVD BLDG 2
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-5251
Practice Address - Country:US
Practice Address - Phone:954-990-7171
Practice Address - Fax:954-530-5992
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW16190101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)