Provider Demographics
NPI:1366443715
Name:WEGNER, LORI JEAN (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:JEAN
Last Name:WEGNER
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1601
Mailing Address - Country:US
Mailing Address - Phone:952-442-4437
Mailing Address - Fax:952-442-3084
Practice Address - Street 1:540 E 1ST ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1601
Practice Address - Country:US
Practice Address - Phone:952-442-4437
Practice Address - Fax:952-442-3084
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9460104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN66DO5WEOtherBLUE CROSS BLUE SHIELD
MN682523100Medicaid
MN6228790OtherUBH MEDICA
MN172641OtherU-CARE
MN6828790OtherUBH-MEDICA
MN1017124OtherPREFERRED ONE
MNHP23812OtherHEALTH PARTNERS
800001379Medicare ID - Type Unspecified