Provider Demographics
NPI:1760940464
Name:WAGSTAFF, MARY ELIZABETH (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:WAGSTAFF
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 1:35 UPLAND WAY
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-3475
Mailing Address - Country:US
Mailing Address - Phone:207-266-4396
Mailing Address - Fax:
Practice Address - Street 1:SEAPORT VILLAGE HEALTHCARE
Practice Address - Street 2:19 GENERAL MOORE WAY
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605
Practice Address - Country:US
Practice Address - Phone:207-667-9336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT955225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology