Provider Demographics
NPI:1134322639
Name:WAGNER, JOSEPH HERMAN (ST)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:HERMAN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 WEATHERTON PL
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7439
Mailing Address - Country:US
Mailing Address - Phone:636-391-7643
Mailing Address - Fax:
Practice Address - Street 1:9445 LITZSINGER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2113
Practice Address - Country:US
Practice Address - Phone:314-968-2350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01668235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist