Provider Demographics
NPI:1386852937
Name:WAGNER, TERRY J (LMP)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 673
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-0673
Mailing Address - Country:US
Mailing Address - Phone:425-348-4649
Mailing Address - Fax:425-348-0478
Practice Address - Street 1:2615 W CASINO RD
Practice Address - Street 2:SUITE 1A
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-2124
Practice Address - Country:US
Practice Address - Phone:425-348-4649
Practice Address - Fax:425-348-0478
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018843225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist