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General NPI Number Information
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NPI Number | 1013570746
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Entity Type | Individual
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Provider Name | KELLY SUSAN WAGNER M.S., CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 04/18/2019
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Last Update Date | 04/18/2019
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Provider Practice Location Address
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Address Line | 8902 OLD HARFORD RD
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City | BALTIMORE
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State | MD
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Zip | 21234-2646
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Country | US
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Telephone | 443-829-0399
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Fax |
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Provider Business Mailing Address
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Address Line | 3981 FOREST VALLEY RD
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City | PARKVILLE
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State | MD
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Zip | 21234-1433
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Country | US
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Telephone | 443-829-0399
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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