Provider Demographics
NPI:1639338478
Name:WAGNER, MELISSA A (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:SOUDERTON
Mailing Address - State:PA
Mailing Address - Zip Code:18964-2054
Mailing Address - Country:US
Mailing Address - Phone:215-723-2697
Mailing Address - Fax:215-723-2742
Practice Address - Street 1:207 W SUMMIT ST
Practice Address - Street 2:
Practice Address - City:SOUDERTON
Practice Address - State:PA
Practice Address - Zip Code:18964-2054
Practice Address - Country:US
Practice Address - Phone:215-723-2697
Practice Address - Fax:215-723-2742
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA00225700000X
PAOC008769225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist