Provider Demographics
NPI:1538633797
Name:WAGNER, STEPHANIE L (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SOUL TO SOLES
Other - Middle Name:THERAPEUTIC
Other - Last Name:MASSAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:1106 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17404-3414
Mailing Address - Country:US
Mailing Address - Phone:717-424-5339
Mailing Address - Fax:
Practice Address - Street 1:1106 W MARKET ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17404-3414
Practice Address - Country:US
Practice Address - Phone:717-424-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG005181225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist