Provider Demographics
NPI:1811175839
Name:WAGONER, VALERIE ANN (SLP)
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:ANN
Last Name:WAGONER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 SOUTH FRUITLAND
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371
Mailing Address - Country:US
Mailing Address - Phone:253-435-6576
Mailing Address - Fax:253-840-8915
Practice Address - Street 1:402 15TH AVE SE
Practice Address - Street 2:SUITE 100
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3709
Practice Address - Country:US
Practice Address - Phone:253-697-5200
Practice Address - Fax:253-697-5145
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00004583235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist