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NPI Code Detail

MEDICARE: MELANIE WAGNER M.A., CCC-SLP

MEDICARE: MELANIE WAGNER M.A., 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
1235Z00000XSpeech-Language Pathologist004060CT

General Provider Information

NPI Number : 1558509190
Entity Type Code : Individual
Provider Name (Legal Business Name) : MELANIE WAGNER M.A., CCC-SLP
Provider Business Mailing Address
First Line : 143 MORGAN FARMS DR
Second Line :
City : SOUTH WINDSOR
State : CT
Zip : 06074-1373
Country : US
Telephone Number : 860-268-2371
Fax Number : 860-666-2086
Provider Business Practice Location Address
First Line : 256 NEW BRITAIN AVE
Second Line :
City : NEWINGTON
State : CT
Zip : 06111-4416
Country : US
Telephone Number : 860-666-5689
Fax Number : 860-666-2086
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/03/2009
Last Update Date : 02/03/2009

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