Provider Demographics
NPI:1013570746
Name:WAGNER, KELLY SUSAN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUSAN
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 1:3981 FOREST VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-1433
Mailing Address - Country:US
Mailing Address - Phone:443-829-0399
Mailing Address - Fax:
Practice Address - Street 1:8902 OLD HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21234-2646
Practice Address - Country:US
Practice Address - Phone:443-829-0399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist