Provider Demographics
NPI:1346540333
Name:WAGNER, SONJA A (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:SONJA
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:SONJA
Other - Middle Name:A
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MASSAGE THERAPIST
Mailing Address - Street 1:7056 JENAYA CT
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-8507
Mailing Address - Country:US
Mailing Address - Phone:064-546-4368
Mailing Address - Fax:
Practice Address - Street 1:5537 OLD U.S 93
Practice Address - Street 2:SUITE A
Practice Address - City:FLORENCE
Practice Address - State:MT
Practice Address - Zip Code:59833
Practice Address - Country:US
Practice Address - Phone:406-679-0496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LIC-20110225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist