Provider Demographics
NPI:1215173729
Name:WAGNER, ELISE MELANIE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:MELANIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 E 41ST ST
Mailing Address - Street 2:#1D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-5956
Mailing Address - Country:US
Mailing Address - Phone:212-972-3691
Mailing Address - Fax:212-678-3718
Practice Address - Street 1:333 E 41ST ST
Practice Address - Street 2:#1D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-5956
Practice Address - Country:US
Practice Address - Phone:212-972-3691
Practice Address - Fax:212-678-3718
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011331-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist