Provider Demographics
NPI:1629673751
Name:WAGAR, STEVIE FANDANGO (COTA/L)
Entity Type:Individual
Prefix:
First Name:STEVIE
Middle Name:FANDANGO
Last Name:WAGAR
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4509 E SILVER PINE RD
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:WA
Mailing Address - Zip Code:99005-8707
Mailing Address - Country:US
Mailing Address - Phone:509-230-7500
Mailing Address - Fax:
Practice Address - Street 1:714 W PINE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:WA
Practice Address - Zip Code:99156-9046
Practice Address - Country:US
Practice Address - Phone:509-447-2441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60991827224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant