Provider Demographics
NPI:1275236093
Name:WAGNER, HAILEY (MOT)
Entity Type:Individual
Prefix:MS
First Name:HAILEY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15824-1038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:PA
Practice Address - Zip Code:15824-1038
Practice Address - Country:US
Practice Address - Phone:814-265-8265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC017951225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist