Healthcare Provider Details

I. General information

NPI: 1881821627
Provider Name (Legal Business Name): GRETCHEN ELIZABETH WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 06/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1732 DEROCHE CIR SUITE B
GRAMERCY LA
70052-3548
US

IV. Provider business mailing address

311 S RIVER POINTE
LA PLACE LA
70068-2958
US

V. Phone/Fax

Practice location:
  • Phone: 225-868-0309
  • Fax: 225-869-0271
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3389
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: