Provider Demographics
NPI:1760849830
Name:WAGGENER, ANGELA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WAGGENER
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 1:5021 MARINEWAY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-1809
Mailing Address - Country:US
Mailing Address - Phone:405-555-5555
Mailing Address - Fax:
Practice Address - Street 1:101 WATERMERE DR
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-8116
Practice Address - Country:US
Practice Address - Phone:817-431-8668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106854235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist