Provider Demographics
NPI:1518095389
Name:WAGAMON, CATHY LINN (NCTMB, RNC)
Entity Type:Individual
Prefix:MRS
First Name:CATHY
Middle Name:LINN
Last Name:WAGAMON
Suffix:
Gender:F
Credentials:NCTMB, RNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17431 INTERLACHEN DR. NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304
Mailing Address - Country:US
Mailing Address - Phone:763-784-6586
Mailing Address - Fax:
Practice Address - Street 1:17431 INTERLACHEN DR. NE
Practice Address - Street 2:
Practice Address - City:HAM LAKE
Practice Address - State:MN
Practice Address - Zip Code:55304
Practice Address - Country:US
Practice Address - Phone:763-784-6586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8519-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist