Provider Demographics
NPI:1962040766
Name:WAGSHALL, PENINA
Entity type:Individual
Prefix:
First Name:PENINA
Middle Name:
Last Name:WAGSHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PENINA
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:129 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710-1739
Mailing Address - Country:US
Mailing Address - Phone:347-756-0707
Mailing Address - Fax:
Practice Address - Street 1:129 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-1739
Practice Address - Country:US
Practice Address - Phone:347-756-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
CT7894235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174400000XOther Service ProvidersSpecialist