Provider Demographics
NPI:1720367147
Name:WAGNER, MIRIAM ELIZABETH (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:ELIZABETH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:301 PINEHAVEN STREET EXT
Mailing Address - Street 2:
Mailing Address - City:LAURENS
Mailing Address - State:SC
Mailing Address - Zip Code:29360-2671
Mailing Address - Country:US
Mailing Address - Phone:864-984-6584
Mailing Address - Fax:864-984-6464
Practice Address - Street 1:301 PINEHAVEN STREET EXT
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-2671
Practice Address - Country:US
Practice Address - Phone:864-984-6584
Practice Address - Fax:864-984-6464
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4351235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist