MEDICARE: SAMANTHA ROSE WAGNER MA CCC-SLP TSSLD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	033514	NY

General Provider Information

NPI Number	:	1053185405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA ROSE WAGNER MA CCC-SLP TSSLD

Provider Business Mailing Address
First Line	:	7850 83RD ST
Second Line	:
City	:	GLENDALE
State	:	NY
Zip	:	11385-7641
Country	:	US
Telephone Number	:	718-366-1043
Fax Number	:

Provider Business Practice Location Address
First Line	:	4829 37TH ST
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-1903
Country	:	US
Telephone Number	:	646-621-1320
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2023
Last Update Date	:	05/02/2024

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