Provider Demographics
NPI:1275688145
Name:WAGNER, JOANNE L (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:MS
Other - First Name:JOANNE
Other - Middle Name:L
Other - Last Name:WAITKUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8114
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37414-0114
Mailing Address - Country:US
Mailing Address - Phone:847-699-7301
Mailing Address - Fax:423-622-1556
Practice Address - Street 1:368 FOURTH ST
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4309
Practice Address - Country:US
Practice Address - Phone:931-484-3301
Practice Address - Fax:423-622-1556
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6600235Z00000X
IL146-000817235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146-000817OtherSTATE LICENCE
TN6600OtherSTATE TN SLP LICENSE