Provider Demographics
NPI:1356667679
Name:WAGNER, AMY MARIE (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPTA
Mailing Address - Street 1:5065 WAKE ROBIN RD # 0
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-1334
Mailing Address - Country:US
Mailing Address - Phone:440-221-5270
Mailing Address - Fax:
Practice Address - Street 1:35300 KAISER CT
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-6633
Practice Address - Country:US
Practice Address - Phone:440-510-8047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06888225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant