Provider Demographics
NPI:1245853951
Name:WAGNER, TAYLOR M
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:M
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 1:6305 WARD RD
Mailing Address - Street 2:
Mailing Address - City:SANBORN
Mailing Address - State:NY
Mailing Address - Zip Code:14132-9241
Mailing Address - Country:US
Mailing Address - Phone:716-574-1952
Mailing Address - Fax:
Practice Address - Street 1:2900 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2309
Practice Address - Country:US
Practice Address - Phone:716-871-9883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X, 390200000X
NY390200000X
NY030814-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program