Provider Demographics
NPI:1346781234
Name:WAGNER, SHEILA FORREST (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:FORREST
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:SHEILA
Other - Middle Name:ELAINE
Other - Last Name:FORREST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 RED BUD LN
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3222
Mailing Address - Country:US
Mailing Address - Phone:618-698-3990
Mailing Address - Fax:
Practice Address - Street 1:210 RED BUD LN
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-3222
Practice Address - Country:US
Practice Address - Phone:618-698-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056004524225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherNONE