Provider Demographics
NPI:1730265042
Name:WAGNER, WILLIAM G (LISW)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:G
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2531 CAMPBELL RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-3103
Mailing Address - Country:US
Mailing Address - Phone:505-604-1640
Mailing Address - Fax:
Practice Address - Street 1:1330 LOMAS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-1234
Practice Address - Country:US
Practice Address - Phone:505-604-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-38861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39100201Medicaid