Provider Demographics
NPI:1336814409
Name:WAGNER, ELIZABETH CROSSLEY
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CROSSLEY
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 1:5004 MONUMENT AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-3629
Mailing Address - Country:US
Mailing Address - Phone:804-440-1489
Mailing Address - Fax:
Practice Address - Street 1:7114 COPLE HWY
Practice Address - Street 2:
Practice Address - City:HAGUE
Practice Address - State:VA
Practice Address - Zip Code:22469-2525
Practice Address - Country:US
Practice Address - Phone:804-440-1489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA22040006-42235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist