Provider Demographics
NPI:1841583713
Name:VAN WAGNER, DIANE MAY (OT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MAY
Last Name:VAN WAGNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 9 BOX 4668
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09123-0047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 OAK ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2504
Practice Address - Country:US
Practice Address - Phone:513-984-4909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7400225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics