Provider Demographics
NPI:1497001754
Name:WAGNER, NORA (PT)
Entity Type:Individual
Prefix:
First Name:NORA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-3251
Practice Address - Street 1:705 W PLAINFIELD RD
Practice Address - Street 2:SUIT 1
Practice Address - City:COUNTRYSIDE
Practice Address - State:IL
Practice Address - Zip Code:60525-3684
Practice Address - Country:US
Practice Address - Phone:708-352-1362
Practice Address - Fax:708-352-1365
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist