Provider Demographics
NPI:1477853794
Name:WAGNER, CYNTHIA WISE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:WISE
Last Name:WAGNER
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Gender:F
Credentials:MS, CCC-SLP
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Mailing Address - Street 1:330 BROOKLINE AVE
Mailing Address - Street 2:BETH ISRAEL DEACONESS MED CENTER, WEST CAMPUS, SPAN 106
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-632-7400
Mailing Address - Fax:617-632-7401
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:BETH ISRAEL DEACONESS MED CENTER, WEST CAMPUS, SPAN 106
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-632-7400
Practice Address - Fax:617-632-7401
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
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Provider Licenses
StateLicense IDTaxonomies
MA2680235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist