Provider Demographics
NPI:1851581821
Name:WAGNER, MORENE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MORENE
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 1:300 N KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4636
Mailing Address - Country:US
Mailing Address - Phone:505-622-5976
Mailing Address - Fax:
Practice Address - Street 1:300 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4636
Practice Address - Country:US
Practice Address - Phone:505-622-5976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist