Provider Demographics
NPI:1639654437
Name:WAGNER, AMY ELIZABETH (MS, CF-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELIZABETH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 LENOR DR
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-6711
Mailing Address - Country:US
Mailing Address - Phone:404-903-7712
Mailing Address - Fax:
Practice Address - Street 1:631 MAIN STREET
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:PA
Practice Address - Zip Code:17086
Practice Address - Country:US
Practice Address - Phone:717-694-3434
Practice Address - Fax:717-694-3148
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS1000630235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist