Provider Demographics
NPI:1760908198
Name:WAGNER, ALEXA (SLP)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2488
Mailing Address - Country:US
Mailing Address - Phone:630-584-7530
Mailing Address - Fax:
Practice Address - Street 1:13400 S ROUTE 59 STE 116-326
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-5826
Practice Address - Country:US
Practice Address - Phone:815-267-7334
Practice Address - Fax:630-429-9411
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
IL146014611235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist