Provider Demographics
NPI:1881821627
Name:WAGNER, GRETCHEN ELIZABETH
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:ELIZABETH
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 1:311 S RIVER POINTE
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-2958
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1732 DEROCHE CIR
Practice Address - Street 2:SUITE B
Practice Address - City:GRAMERCY
Practice Address - State:LA
Practice Address - Zip Code:70052-3548
Practice Address - Country:US
Practice Address - Phone:225-868-0309
Practice Address - Fax:225-869-0271
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3389235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist