1144640947 NPI number — SOPHIE R. WAGNER, NM SPEECH-LANGUAGE PATHOLOGIST, LLC

Table of content: (NPI 1144640947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144640947 NPI number — SOPHIE R. WAGNER, NM SPEECH-LANGUAGE PATHOLOGIST, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOPHIE R. WAGNER, NM SPEECH-LANGUAGE PATHOLOGIST, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144640947
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1503 CENTRAL AVE NW
Provider Second Line Business Mailing Address:
UNIT 202
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87104-1180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-401-8204
Provider Business Mailing Address Fax Number:
505-232-3588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1503 CENTRAL AVE NW
Provider Second Line Business Practice Location Address:
UNIT 202
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87104-1180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-401-8204
Provider Business Practice Location Address Fax Number:
505-232-3588
Provider Enumeration Date:
04/18/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
CARYN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
505-980-5334

Provider Taxonomy Codes

  • Taxonomy code: 261QH0700X , with the licence number:  5431 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 81888228 . This is a "MEDICAID, INDIVIDUAL PROVIDER ID, NOT BILLING PROVIDER ID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 47631597 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03272176005 . This is a "CRS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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