Provider Demographics
NPI:1568684942
Name:WAGGONER, MICHELLE RENE (MS-CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENE
Last Name:WAGGONER
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 1:8670 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ALMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54909-9027
Mailing Address - Country:US
Mailing Address - Phone:715-366-2508
Mailing Address - Fax:
Practice Address - Street 1:1401 CHURCHILL ST
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-2027
Practice Address - Country:US
Practice Address - Phone:715-258-8131
Practice Address - Fax:715-258-0179
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2230-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42796300Medicaid