Provider Demographics
NPI:1003392044
Name:WAGNER, ELIZABETH BAILEY (MS OTRL)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:BAILEY
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:BAILEY
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS OTRL
Mailing Address - Street 1:6364 WINDDRIFT AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-8923
Mailing Address - Country:US
Mailing Address - Phone:269-873-0910
Mailing Address - Fax:
Practice Address - Street 1:7161 W Q AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-5951
Practice Address - Country:US
Practice Address - Phone:269-870-7334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist