Provider Demographics
NPI:1396874335
Name:WAGNER, ROGER (MS, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
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 1:3224 W WINCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-3835
Mailing Address - Country:US
Mailing Address - Phone:417-523-1320
Mailing Address - Fax:
Practice Address - Street 1:639 W CHESTNUT EXPY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-3935
Practice Address - Country:US
Practice Address - Phone:417-523-1320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007025212235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist