Provider Demographics
NPI:1689801862
Name:WAGNER, DAWN G (LMT, BCTMB)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:G
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14438 W CENTER RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-3217
Mailing Address - Country:US
Mailing Address - Phone:402-740-9731
Mailing Address - Fax:
Practice Address - Street 1:14438 W CENTER RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3217
Practice Address - Country:US
Practice Address - Phone:402-740-9731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1665225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist