Ivy Christine Wagner, DBH, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

L11519 Issued in OR

Practice address

780 2ND St SE Ste 10
Bandon, OR 97411-8354

Phone

(541) 329-2144

NPI assigned

Nov 21, 2017

Last updated

Aug 16, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in OR

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Interoperability endpoints

• FHIR API: https://fhir.meditouchehr.com/api/fhir/r4/

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Roseburg Therapy LLC

  • Mental Health Counselor
  • Roseburg, OR
  • NPI 1538665013
  Medicare reassignment
• Bandon Community Health Center

  • Primary Care Clinic/Center
  • Bandon, OR
  • NPI 1033348289
  NPD
• Bandon Community Health Ctr

  dba Coast Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Port Orford, OR
  • NPI 1013587484
  NPD
• Frontier Foot and Ankle Specialists LLC

  • Foot & Ankle Surgery Podiatrist
  • Bandon, OR
  • NPI 1003432204
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1511222400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1723766400000",
    "number": "1346754702",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "790 BLUFF AVE SW",
            "city": "BANDON",
            "state": "OR",
            "postal_code": "974119614",
            "telephone_number": "503-984-9243"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "780 2ND ST SE STE 10",
            "city": "BANDON",
            "state": "OR",
            "postal_code": "974118354",
            "telephone_number": "541-329-2144"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "IVY",
        "middle_name": "CHRISTINE",
        "name_prefix": "Dr.",
        "credential": "DBH, LCSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-11-21",
        "last_updated": "2024-08-16",
        "certification_date": "2024-08-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "OR",
            "license": "L11519",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Thrifty Payless Inc (Rite Aid Pharmacy 06710)
• Tri- City Podiatric Physicians & Surgeons LTD
• Amie Michelle Turner, LMT
• Ingrid Maria Tyson, MS FNP
• Tina Elaine Vecera, LAC
• Susan Folmar Wagner, QMHP, MS
• Gabrielle Schaefer Weishoff, D.M.D.
• Well Within
• William M. Soper, DDS
• Stephen Wilson, RPH

• Clinical Social Worker in Bandon, OR
• Providers in Bandon, OR by specialty
• Clinical Social Worker in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 16, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.