Provider Demographics
NPI:1558509190
Name:WAGNER, MELANIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:
Other - Last Name:TOMLINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:143 MORGAN FARMS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-1373
Mailing Address - Country:US
Mailing Address - Phone:860-268-2371
Mailing Address - Fax:860-666-2086
Practice Address - Street 1:256 NEW BRITAIN AVE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-4416
Practice Address - Country:US
Practice Address - Phone:860-666-5689
Practice Address - Fax:860-666-2086
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004060235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist