Provider Demographics
NPI:1275047417
Name:GRANATO-WAGNER, VANESSA (MS, CCC-SLP/L)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:
Last Name:GRANATO-WAGNER
Suffix:
Gender:F
Credentials:MS, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7652 166TH PL
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2416
Mailing Address - Country:US
Mailing Address - Phone:708-415-8102
Mailing Address - Fax:
Practice Address - Street 1:6020 151ST ST
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-1841
Practice Address - Country:US
Practice Address - Phone:708-687-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008357235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist