Provider Demographics
NPI:1760023022
Name:WAGGENSPACK, ROSALEEN C (LMT)
Entity Type:Individual
Prefix:
First Name:ROSALEEN
Middle Name:C
Last Name:WAGGENSPACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 BELVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1427
Mailing Address - Country:US
Mailing Address - Phone:937-286-6088
Mailing Address - Fax:
Practice Address - Street 1:1563 E DOROTHY LN STE 200
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-3856
Practice Address - Country:US
Practice Address - Phone:937-286-6088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.01665172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist