Provider Demographics
NPI:1891440525
Name:WAGNER, STEPHANIE VICTORIA (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:VICTORIA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:VICTORIA
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:PO BOX 87294
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-7294
Mailing Address - Country:US
Mailing Address - Phone:910-483-8331
Mailing Address - Fax:910-483-8335
Practice Address - Street 1:1289 OLIVER ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4450
Practice Address - Country:US
Practice Address - Phone:910-483-8331
Practice Address - Fax:910-483-8335
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14825225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist