Provider Demographics
NPI:1174616551
Name:WAGNER, DIANA J (MA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8850 STANFORD BLVD STE 1700
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4765
Mailing Address - Country:US
Mailing Address - Phone:410-964-9511
Mailing Address - Fax:410-964-9513
Practice Address - Street 1:8850 STANFORD BLVD STE 1700
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-4765
Practice Address - Country:US
Practice Address - Phone:410-964-9511
Practice Address - Fax:410-964-9513
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD562231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist