Provider Demographics
NPI:1740788397
Name:WAGNER, LESLIE (MS, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:WAGNER
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 1:208 HOPKINS RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-1817
Mailing Address - Country:US
Mailing Address - Phone:443-286-6926
Mailing Address - Fax:
Practice Address - Street 1:3501 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-4406
Practice Address - Country:US
Practice Address - Phone:410-444-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03853235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist