Provider Demographics
NPI:1871832691
Name:WAGNER, SHANNON (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 JENNIFER CT
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:CA
Mailing Address - Zip Code:94507-1261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 RYAN INDUSTRIAL CT
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1772
Practice Address - Country:US
Practice Address - Phone:925-855-9810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20207235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist