Provider Demographics
NPI:1750673513
Name:WAGNER, KRISTY E (COTA)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:E
Other - Last Name:REINERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6709 WHITETAIL DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINNECONNE
Mailing Address - State:WI
Mailing Address - Zip Code:54986-8717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923
Practice Address - Country:US
Practice Address - Phone:920-361-5534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4761027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant