Individual
SOPHIE RUTH WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
SLP
Contact information
Practice address
1503 CENTRAL AVE NW, UNIT 202, ALBUQUERQUE, NM 87104-1180
(505) 401-8204
(505) 232-3593
Mailing address
1503 CENTRAL AVE NW, UNIT 202, ALBUQUERQUE, NM 87104-1180
(505) 401-8204
(505) 232-3593
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
47631597
MEDICAID, INDIVIDUAL PROVIDER ID, NOT BILLING PROVIDER ID
NM
05
—
47631597
—
NM
Enumeration date
09/27/2012
Last updated
09/04/2014
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