Provider Demographics
NPI:1407998651
Name:WAGONHEIM, NICOLE A M (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:A M
Last Name:WAGONHEIM
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7455 PINEWILD RD
Mailing Address - Street 2:
Mailing Address - City:SEVEN VALLEYS
Mailing Address - State:PA
Mailing Address - Zip Code:17360-9165
Mailing Address - Country:US
Mailing Address - Phone:717-728-0753
Mailing Address - Fax:
Practice Address - Street 1:7401 OSLER DR
Practice Address - Street 2:SUITE 110
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7673
Practice Address - Country:US
Practice Address - Phone:410-296-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02799235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD613155OtherBC BS