Provider Demographics
NPI:1255506291
Name:WAGUESPACK, GLENN MICHAEL (MS)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:MICHAEL
Last Name:WAGUESPACK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 EAST BERT KOUNS LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-798-4442
Mailing Address - Fax:318-798-4439
Practice Address - Street 1:1455 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5634
Practice Address - Country:US
Practice Address - Phone:318-798-4442
Practice Address - Fax:318-798-4439
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA416231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1688568Medicaid
LA414304YJS0Medicare PIN