Provider Demographics
NPI:1457692428
Name:WAGNER, CARLY MARIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:MARIE
Other - Last Name:SJODIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:742 STERBENZ DR
Mailing Address - Street 2:ST CROIX THERAPY
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8327
Mailing Address - Country:US
Mailing Address - Phone:715-386-2128
Mailing Address - Fax:715-386-6119
Practice Address - Street 1:742 STERBENZ DR
Practice Address - Street 2:ST CROIX THERAPY
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8327
Practice Address - Country:US
Practice Address - Phone:715-386-2128
Practice Address - Fax:715-386-6119
Is Sole Proprietor?:No
Enumeration Date:2013-03-15
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3781235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3781OtherWISCONSIN LICENSE