Provider Demographics
NPI:1467703694
Name:WAGNER, SOPHIE RUTH (SLP)
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:RUTH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:SOPHIE
Other - Middle Name:RUTH
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:1503 CENTRAL AVE NW
Mailing Address - Street 2:UNIT 202
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-1180
Mailing Address - Country:US
Mailing Address - Phone:505-401-8204
Mailing Address - Fax:505-232-3593
Practice Address - Street 1:1503 CENTRAL AVE NW
Practice Address - Street 2:UNIT 202
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-1180
Practice Address - Country:US
Practice Address - Phone:505-401-8204
Practice Address - Fax:505-232-3593
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47631597OtherMEDICAID, INDIVIDUAL PROVIDER ID, NOT BILLING PROVIDER ID
NM47631597Medicaid