Provider Demographics
NPI:1760066393
Name:WAGNER, TORIE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:TORIE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3462 ANDREW CT APT 203
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-2365
Mailing Address - Country:US
Mailing Address - Phone:707-813-1315
Mailing Address - Fax:
Practice Address - Street 1:9909 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6361
Practice Address - Country:US
Practice Address - Phone:240-864-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA009172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer