Provider Demographics
NPI:1720293723
Name:WAGNER, LESLIE (MS,CCC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS,CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 TIEMANN PL
Mailing Address - Street 2:APT # 55
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-3332
Mailing Address - Country:US
Mailing Address - Phone:212-662-7584
Mailing Address - Fax:
Practice Address - Street 1:55 TIEMANN PL
Practice Address - Street 2:APT # 55
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-3332
Practice Address - Country:US
Practice Address - Phone:212-662-7584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012587-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist