Provider Demographics
NPI:1285847954
Name:WAGENHEIM, HOWARD KENNETH (LPT LICENSED PHYSICA)
Entity Type:Individual
Prefix:MR
First Name:HOWARD
Middle Name:KENNETH
Last Name:WAGENHEIM
Suffix:
Gender:M
Credentials:LPT LICENSED PHYSICA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5411 OLD FREDERICK RD
Mailing Address - Street 2:#16
Mailing Address - City:BALT
Mailing Address - State:MD
Mailing Address - Zip Code:21229
Mailing Address - Country:US
Mailing Address - Phone:410-747-0158
Mailing Address - Fax:410-747-3828
Practice Address - Street 1:5411 OLD FREDERICK RD
Practice Address - Street 2:#16
Practice Address - City:BALT
Practice Address - State:MD
Practice Address - Zip Code:21229
Practice Address - Country:US
Practice Address - Phone:410-747-0158
Practice Address - Fax:410-747-3828
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13512225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
J915HKMedicare ID - Type Unspecified