Provider Demographics
NPI:1275082398
Name:WAGNER, CAROLYN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10631 E 34TH PL
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-5979
Mailing Address - Country:US
Mailing Address - Phone:516-633-3592
Mailing Address - Fax:
Practice Address - Street 1:10631 E 34TH PL
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-5979
Practice Address - Country:US
Practice Address - Phone:516-633-3592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-30
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6121235Z00000X
AZSLP13494235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist