Provider Demographics
NPI:1821333485
Name:WAGNER, EMILY MARIE
Entity Type:Individual
Prefix:MISS
First Name:EMILY
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3823 N SOUTHPORT AVE
Mailing Address - Street 2:#2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-5933
Mailing Address - Country:US
Mailing Address - Phone:773-633-3789
Mailing Address - Fax:
Practice Address - Street 1:3823 N SOUTHPORT AVE
Practice Address - Street 2:#2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-5933
Practice Address - Country:US
Practice Address - Phone:773-633-3789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008770235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist