Provider Demographics
NPI:1225566003
Name:WAGONSCHUTZ, CARLY GAIL (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:CARLY
Middle Name:GAIL
Last Name:WAGONSCHUTZ
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 SCHAVEY RD
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-9523
Mailing Address - Country:US
Mailing Address - Phone:517-749-5320
Mailing Address - Fax:
Practice Address - Street 1:2530 MARFITT RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6343
Practice Address - Country:US
Practice Address - Phone:866-486-8811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202008251224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant