Provider Demographics
NPI:1164626867
Name:WAGSTAFF, ELLEN F
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:F
Last Name:WAGSTAFF
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 1:428 MOONLIGHT LN
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:508 S ADAMS ST
Practice Address - Street 2:STE. 102
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2147
Practice Address - Country:US
Practice Address - Phone:817-878-2834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19323235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist