Provider Demographics
NPI:1679963482
Name:WAGNER, SUSAN ANGLIN (MS)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANGLIN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 KIRK LN
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2217
Mailing Address - Country:US
Mailing Address - Phone:610-627-4654
Mailing Address - Fax:
Practice Address - Street 1:205 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3052
Practice Address - Country:US
Practice Address - Phone:610-627-4654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-01
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007001101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor