Provider Demographics
NPI:1982019519
Name:WAGAMON, DANIELLE REYNOLDS (DPT)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:REYNOLDS
Last Name:WAGAMON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7310 RITCHIE HWY 500
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3099
Mailing Address - Country:US
Mailing Address - Phone:410-766-4047
Mailing Address - Fax:
Practice Address - Street 1:6949 OLD DOMINION DR
Practice Address - Street 2:SUITE 330
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101
Practice Address - Country:US
Practice Address - Phone:703-848-9333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25018225100000X
VA23052086412251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist