Provider Demographics
NPI:1083216717
Name:WAGNER, BROCHA
Entity Type:Individual
Prefix:MRS
First Name:BROCHA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HAMASPIK WAY
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-8451
Mailing Address - Country:US
Mailing Address - Phone:845-774-8400
Mailing Address - Fax:845-774-0506
Practice Address - Street 1:1 HAMASPIK WAY
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-8451
Practice Address - Country:US
Practice Address - Phone:845-774-8400
Practice Address - Fax:845-774-0506
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY745313769OtherFIDELIS CARE