MEDICARE: KELLEY WAGNER MS, CCC-SLP

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	112685	TX

General Provider Information

NPI Number	:	1376023986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY WAGNER MS, CCC-SLP

Provider Business Mailing Address
First Line	:	9201 BRODIE LN UNIT 2601
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78748-6290
Country	:	US
Telephone Number	:	512-517-3906
Fax Number	:

Provider Business Practice Location Address
First Line	:	9201 BRODIE LN UNIT 2601
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78748-6290
Country	:	US
Telephone Number	:	512-517-3906
Fax Number	:

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

Provider Enumeration Date	:	08/14/2018
Last Update Date	:	08/14/2018

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Directions to “ KELLEY WAGNER MS, CCC-SLP” Practice Location

Language	Start Address	Practice Location

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