Provider Demographics
NPI:1275583544
Name:WAGNER, CAROLE SUE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:CAROLE
Middle Name:SUE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 PHEASANT WOODS DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63021-4300
Mailing Address - Country:US
Mailing Address - Phone:636-394-7429
Mailing Address - Fax:
Practice Address - Street 1:1 JEFFERSON BARRACKS DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-4181
Practice Address - Country:US
Practice Address - Phone:314-894-6505
Practice Address - Fax:314-845-5077
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004012994174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist