Provider Demographics
NPI:1780376301
Name:WAGNER, SARA ELIDA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:ELIDA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14811 ADIOS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-0977
Mailing Address - Country:US
Mailing Address - Phone:210-240-4469
Mailing Address - Fax:
Practice Address - Street 1:8961 TESORO DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-6209
Practice Address - Country:US
Practice Address - Phone:210-407-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113647235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist