Provider Demographics
NPI:1437271590
Name:WAGNER, DONNA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 E CLARE CT
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-9412
Mailing Address - Country:US
Mailing Address - Phone:847-962-9229
Mailing Address - Fax:847-535-7847
Practice Address - Street 1:660 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1659
Practice Address - Country:US
Practice Address - Phone:847-535-8962
Practice Address - Fax:847-535-7847
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008880235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist