Provider Demographics
NPI:1902221187
Name:LAGORE, WENDI (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:WENDI
Middle Name:
Last Name:LAGORE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MRS
Other - First Name:WENDI
Other - Middle Name:
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:GREEN FOREST
Mailing Address - State:AR
Mailing Address - Zip Code:72638-1950
Mailing Address - Country:US
Mailing Address - Phone:870-438-5201
Mailing Address - Fax:870-438-6214
Practice Address - Street 1:805 TOMMY RATZLAFF AVE
Practice Address - Street 2:
Practice Address - City:GREEN FOREST
Practice Address - State:AR
Practice Address - Zip Code:72638-2911
Practice Address - Country:US
Practice Address - Phone:870-438-5201
Practice Address - Fax:870-438-6214
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013033612224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant