Provider Demographics
NPI:1386885101
Name:WAGNER, BROOKE A (ST)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 N MORTON AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-1426
Mailing Address - Country:US
Mailing Address - Phone:309-266-5488
Mailing Address - Fax:309-266-9144
Practice Address - Street 1:1909 N MORTON AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-1426
Practice Address - Country:US
Practice Address - Phone:309-266-5488
Practice Address - Fax:309-266-9144
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146009517235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5377460003OtherRR MEDICARE