Individual
AUTUMN WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LISW
Contact information
Practice address
4641 FULTON DR NW, CANTON, OH 44718-2384
(330) 433-6075
Mailing address
4641 FULTON DR NW, CANTON, OH 44718-2384
(330) 433-6075
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
I.2506755
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0208461
—
OH
01
—
I.2506755
LISW
OH
Enumeration date
11/09/2015
Last updated
10/09/2025
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