Provider Demographics
NPI:1639578644
Name:WAGNER, JOAN
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 BROOK VIEW DR
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-3533
Mailing Address - Country:US
Mailing Address - Phone:330-815-1514
Mailing Address - Fax:
Practice Address - Street 1:150 N MILLER RD
Practice Address - Street 2:BLDG 150
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3770
Practice Address - Country:US
Practice Address - Phone:330-630-1860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA0853224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant