Individual
MR. KEVIN DALE WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MSW
Contact information
Practice address
1500 N WESTWOOD BLVD, POPLAR BLUFF, MO 63901-3318
(573) 778-4631
Mailing address
1500 N WESTWOOD BLVD, POPLAR BLUFF, MO 63901-3318
(573) 778-4631
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
SW 04619
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
498307107
—
MO
Enumeration date
06/05/2007
Last updated
12/26/2013
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