Doctor Name: | MRS. KELLY ANNE WAGNER |
NPI Number: | 1235562307 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | SLP |
License Number: | TSLP-2301 |
Business Practice Address: | 331 E Park St Weiser, ID - 836722053 |
Business Phone Number: | 2085490206 |
Business Fax Number: | 2085490536 |
Mailing Address: | 331 E Park St, WEISER |
State: | ID |
Postal Code: | 836722053 |
Phone Number: | 2088902995 |
Fax Number: | |
NPI Enumeration Date: | 08/13/2013 |
NPI Last Update Date: | 08/13/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 235Z00000X |
License Number: | TSLP-2301 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | ID |
Taxonomy Type: | Speech, Language and Hearing Service Providers |
Taxonomy Classification: | Speech-Language Pathologist |
Taxonomy Specialization: | |
Taxonomy Definition: | A speech pathologist is a person qualified by a master |