Provider Demographics
NPI:1780205906
Name:WAGNER, CORINNE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CORINNE
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 1:1475 CAPITOL ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-7850
Mailing Address - Country:US
Mailing Address - Phone:971-599-1712
Mailing Address - Fax:888-835-4257
Practice Address - Street 1:1475 CAPITOL ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-7850
Practice Address - Country:US
Practice Address - Phone:971-599-1712
Practice Address - Fax:888-835-4257
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR016526235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist