Provider Demographics
NPI:1700164142
Name:WAGNER MACDONALD, CHERYL ANN
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:ANN
Last Name:WAGNER MACDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CHERYL
Other - Middle Name:ANN
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4100 BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14544-9738
Mailing Address - Country:US
Mailing Address - Phone:585-554-6441
Mailing Address - Fax:585-554-6176
Practice Address - Street 1:4100 BALDWIN RD
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:NY
Practice Address - Zip Code:14544-9738
Practice Address - Country:US
Practice Address - Phone:585-554-6441
Practice Address - Fax:585-554-6176
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015245235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist