Provider Demographics
NPI:1790159069
Name:WAGNER, LUKE (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:LUKE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 TOWN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-2166
Mailing Address - Country:US
Mailing Address - Phone:321-557-7406
Mailing Address - Fax:
Practice Address - Street 1:8132 HUDSON AVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-8571
Practice Address - Country:US
Practice Address - Phone:727-863-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 11468224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant