1457692428 NPI number — CARLY MARIE WAGNER MS, CCC-SLP

Table of content: CARLY MARIE WAGNER MS, CCC-SLP (NPI 1457692428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457692428 NPI number — CARLY MARIE WAGNER MS, CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
CARLY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SJODIN
Provider Other First Name:
CARLY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, CCC-SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457692428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
742 STERBENZ DR
Provider Second Line Business Mailing Address:
ST CROIX THERAPY
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54016-8327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-386-2128
Provider Business Mailing Address Fax Number:
715-386-6119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
742 STERBENZ DR
Provider Second Line Business Practice Location Address:
ST CROIX THERAPY
Provider Business Practice Location Address City Name:
HUDSON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54016-8327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-386-2128
Provider Business Practice Location Address Fax Number:
715-386-6119
Provider Enumeration Date:
03/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  3781 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3781 . This is a "WISCONSIN LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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