MEDICARE: HEATHER WAGNER 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	2016026452	MO

General Provider Information

NPI Number	:	1649724204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER WAGNER SLP

Provider Business Mailing Address
First Line	:	621 NE 5TH ST
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-2976
Country	:	US
Telephone Number	:	573-579-5273
Fax Number	:

Provider Business Practice Location Address
First Line	:	5020 NW VALLEY VIEW RD
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64015-2345
Country	:	US
Telephone Number	:	816-874-3670
Fax Number	:

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

Provider Enumeration Date	:	08/11/2016
Last Update Date	:	05/03/2019

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