Provider Demographics
NPI:1598384877
Name:WAGNER, DANIELLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTR/L
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 32
Mailing Address - Street 2:
Mailing Address - City:SHELLSBURG
Mailing Address - State:IA
Mailing Address - Zip Code:52332-0032
Mailing Address - Country:US
Mailing Address - Phone:507-491-3239
Mailing Address - Fax:
Practice Address - Street 1:745 COMMUNITY DR UNIT H
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-6709
Practice Address - Country:US
Practice Address - Phone:319-626-2257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA099563225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist