Healthcare Provider Details

I. General information

NPI: 1841728581
Provider Name (Legal Business Name): KATHLEEN WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 05/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 COUNTY ROAD B2 W STE 100
ROSEVILLE MN
55113-2722
US

IV. Provider business mailing address

114 118TH AVE NE
BLAINE MN
55434-1929
US

V. Phone/Fax

Practice location:
  • Phone: 651-636-4155
  • Fax:
Mailing address:
  • Phone: 320-491-6534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number9873
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: