Provider Demographics
NPI:1750861639
Name:WAGNER, AUDREY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:EUBANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:35535 6TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-8110
Mailing Address - Country:US
Mailing Address - Phone:253-874-5445
Mailing Address - Fax:
Practice Address - Street 1:34515 9TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6761
Practice Address - Country:US
Practice Address - Phone:253-944-7970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60973136235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist