Provider Demographics
NPI:1598816142
Name:WAGELIE, TERESA (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:
Last Name:WAGELIE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5156 S 197TH AVENUE CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-3679
Mailing Address - Country:US
Mailing Address - Phone:402-290-0137
Mailing Address - Fax:402-597-0382
Practice Address - Street 1:5156 S 197TH AVENUE CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-3679
Practice Address - Country:US
Practice Address - Phone:402-290-0137
Practice Address - Fax:402-597-0382
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE424225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE06584OtherBCBSNE