Active NPI
Theressa Marie Wagner, MSW LCSW
- Clinical Social Worker
- Centreville, MI
National Provider Identifier
1326196759
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 6801078479
- Practice address
- 677A East Main
Centreville, MI 49032 - Phone
- (269) 467-1000
- NPI assigned
- Jan 8, 2007
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 6801078479 | MI | Primary |
Addresses
Primary practice location
677A East Main
Centreville, MI 49032
Mailing address
677A East Main
Centreville, MI 49032
Phone (269) 467-1000
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1708146 | Medicaid | MI |
Other names 1
- Theressa Marie Wagner Kullok
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6801078479 | MI | MD | Clinical Social Worker |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Summit Pointe | Clinical | Past | Accepting new patients |
| Community Mental Health Services of St Joseph County | Past | Accepting new patients | |
| Adapt St. Joe, Inc | Past | Accepting new patients |
Organizations & group practices 3
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Community/Behavioral Health Agency
- Sturgis, MI
- NPI 1316119506
-
dba Community Mental Health and Substance Abuse Services of St Joseph Coun
- Community/Behavioral Health Agency
- Centreville, MI
- NPI 1366438483
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1168214400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1247788800000",
"number": "1326196759",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "677A EAST MAIN",
"city": "CENTREVILLE",
"state": "MI",
"postal_code": "49032",
"telephone_number": "269-467-1000",
"fax_number": "269-467-3075"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "677A EAST MAIN",
"city": "CENTREVILLE",
"state": "MI",
"postal_code": "49032",
"telephone_number": "269-467-1000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNER",
"first_name": "THERESSA",
"middle_name": "MARIE",
"name_prefix": "Ms.",
"credential": "MSW LCSW",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-01-08",
"last_updated": "2009-07-17",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "MI",
"license": "6801078479",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1708146",
"state": "MI"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "THERESSA",
"last_name": "WAGNER KULLOK",
"middle_name": "MARIE",
"code": "1",
"type": "Former Name"
}
]
}Other providers in Centreville, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 17, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.