1265537484 NPI number — MR. IAN JEFFREY AGAR MSW, LCSW, CADC III

Table of content: MR. IAN JEFFREY AGAR MSW, LCSW, CADC III (NPI 1265537484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265537484 NPI number — MR. IAN JEFFREY AGAR MSW, LCSW, CADC III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AGAR
Provider First Name:
IAN
Provider Middle Name:
JEFFREY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW, CADC III
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265537484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W15354 COUNTY HIGHWAY D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WITTTENBERG
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-793-4411
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WAUSAU VETERANS OUTPATIENT CLINIC
Provider Second Line Business Practice Location Address:
515 S. 32ND AVENUE
Provider Business Practice Location Address City Name:
WAUSAU
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-842-2834
Provider Business Practice Location Address Fax Number:
715-845-8211
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  13523 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 7098-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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