Individual
BROOKE A WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ST
Contact information
Practice address
1909 N MORTON AVE, MORTON, IL 61550-1426
(309) 266-5488
(309) 266-9144
Mailing address
1909 N MORTON AVE, MORTON, IL 61550-1426
(309) 266-5488
(309) 266-9144
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
146009517
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5377460003
RR MEDICARE
IL
Enumeration date
03/09/2009
Last updated
02/19/2010
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