Provider Demographics
NPI:1194206243
Name:WAGNER, EMILY GRACE (DT-C)
Entity Type:Individual
Prefix:MISS
First Name:EMILY
Middle Name:GRACE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DT-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11720 PLAZA AMERICA DR FL 9
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4757
Mailing Address - Country:US
Mailing Address - Phone:866-968-7512
Mailing Address - Fax:
Practice Address - Street 1:11720 PLAZA AMERICA DR FL 9
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-4757
Practice Address - Country:US
Practice Address - Phone:866-968-7512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN29001978A2355S0801X
NA222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant