Provider Demographics
NPI:1023507472
Name:WAGNER, KIRSTEN SUZANNE (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KIRSTEN
Middle Name:SUZANNE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MS
Other - First Name:KIRSTEN
Other - Middle Name:SUZANNE
Other - Last Name:STANTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:3035 WOOSTER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116
Mailing Address - Country:US
Mailing Address - Phone:440-356-4365
Mailing Address - Fax:440-333-0910
Practice Address - Street 1:3035 WOOSTER RD
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116
Practice Address - Country:US
Practice Address - Phone:440-356-4365
Practice Address - Fax:440-333-0910
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.11173235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist