Provider Demographics
NPI:1518017797
Name:WAGONER, SANDRA M (OT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:WAGONER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1583
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-1583
Mailing Address - Country:US
Mailing Address - Phone:434-654-7794
Mailing Address - Fax:434-654-7752
Practice Address - Street 1:410 ALBEMARLE SQ
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-7400
Practice Address - Country:US
Practice Address - Phone:434-817-4278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119000123225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA103185Medicare PIN