Provider Demographics
NPI:1225512890
Name:WAGNER, NATALIE RACHEL (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:RACHEL
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WHITINSVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01588-1416
Mailing Address - Country:US
Mailing Address - Phone:508-581-9043
Mailing Address - Fax:
Practice Address - Street 1:68 CHURCH ST
Practice Address - Street 2:
Practice Address - City:WHITINSVILLE
Practice Address - State:MA
Practice Address - Zip Code:01588-1416
Practice Address - Country:US
Practice Address - Phone:508-581-9043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77028235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist