Provider Demographics
NPI:1699830331
Name:WAGNER, ADELYN LEE (OTRL)
Entity Type:Individual
Prefix:MS
First Name:ADELYN
Middle Name:LEE
Last Name:WAGNER
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 1:623 EPPLE FRICKE DR
Mailing Address - Street 2:
Mailing Address - City:HERMANN
Mailing Address - State:MO
Mailing Address - Zip Code:65041-1703
Mailing Address - Country:US
Mailing Address - Phone:573-486-5473
Mailing Address - Fax:
Practice Address - Street 1:509 W. 18TH ST.
Practice Address - Street 2:
Practice Address - City:HERMANN
Practice Address - State:MO
Practice Address - Zip Code:65041-0470
Practice Address - Country:US
Practice Address - Phone:573-486-2191
Practice Address - Fax:573-486-5021
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000587225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist