Provider Demographics
NPI:1871690875
Name:WAGLEY, HOLLY J (MSP, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:J
Last Name:WAGLEY
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:SMITHSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 N BLACK AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3613
Mailing Address - Country:US
Mailing Address - Phone:704-796-0610
Mailing Address - Fax:
Practice Address - Street 1:520 N BLACK AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3613
Practice Address - Country:US
Practice Address - Phone:704-796-0610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8682235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1206OtherLICENSE
FLSA8682OtherSLP STATE LICENSE