Provider Demographics
NPI:1144640947
Name:SOPHIE R. WAGNER, NM SPEECH-LANGUAGE PATHOLOGIST, LLC
Entity type:Organization
Organization Name:SOPHIE R. WAGNER, NM SPEECH-LANGUAGE PATHOLOGIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-980-5334
Mailing Address - Street 1:1503 CENTRAL AVE NW
Mailing Address - Street 2:UNIT 202
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-1180
Mailing Address - Country:US
Mailing Address - Phone:505-401-8204
Mailing Address - Fax:505-232-3588
Practice Address - Street 1:1503 CENTRAL AVE NW
Practice Address - Street 2:UNIT 202
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-1180
Practice Address - Country:US
Practice Address - Phone:505-401-8204
Practice Address - Fax:505-232-3588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-18
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5431261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM81888228OtherMEDICAID, INDIVIDUAL PROVIDER ID, NOT BILLING PROVIDER ID
NM47631597Medicaid
NM03272176005OtherCRS