Healthcare Provider Details

I. General information

NPI: 1144640947
Provider Name (Legal Business Name): SOPHIE R. WAGNER, NM SPEECH-LANGUAGE PATHOLOGIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 CENTRAL AVE NW UNIT 202
ALBUQUERQUE NM
87104-1180
US

IV. Provider business mailing address

1503 CENTRAL AVE NW UNIT 202
ALBUQUERQUE NM
87104-1180
US

V. Phone/Fax

Practice location:
  • Phone: 505-401-8204
  • Fax: 505-232-3588
Mailing address:
  • Phone: 505-401-8204
  • Fax: 505-232-3588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number5431
License Number StateNM

VIII. Authorized Official

Name: MS. CARYN WAGNER
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-980-5334