Provider Demographics
NPI:1740428135
Name:WAGNER, MEGAN THERESA
Entity Type:Individual
Prefix:MS
First Name:MEGAN
Middle Name:THERESA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:THERESA
Other - Last Name:JABLONOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:564 STAFFORD DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-5809
Mailing Address - Country:US
Mailing Address - Phone:330-321-3999
Mailing Address - Fax:
Practice Address - Street 1:6437 RUCKER RD
Practice Address - Street 2:SUITE D
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4885
Practice Address - Country:US
Practice Address - Phone:317-405-9016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46001920A235Z00000X
IN22005964A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist