Provider Demographics
NPI:1710506092
Name:VAN WAGENEN, ANNA-LAURENE (OTR/L)
Entity Type:Individual
Prefix:
First Name:ANNA-LAURENE
Middle Name:
Last Name:VAN WAGENEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-4209
Mailing Address - Country:US
Mailing Address - Phone:410-574-4950
Mailing Address - Fax:
Practice Address - Street 1:6600 RIDGE RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-4209
Practice Address - Country:US
Practice Address - Phone:410-574-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07333225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist