Provider Demographics
NPI:1215541602
Name:WAGENMAN, KARISA (MSED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KARISA
Middle Name:
Last Name:WAGENMAN
Suffix:
Gender:F
Credentials:MSED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 OLD QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-3641
Mailing Address - Country:US
Mailing Address - Phone:908-839-0278
Mailing Address - Fax:
Practice Address - Street 1:14 OLD BRIDGE TPKE
Practice Address - Street 2:
Practice Address - City:SOUTH RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08882-2496
Practice Address - Country:US
Practice Address - Phone:732-698-8786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01039600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist