Provider Demographics
NPI:1023343647
Name:WAGNER, ELIZABETH (OT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name: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 1:9505 NORTHPOINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-3799
Mailing Address - Country:US
Mailing Address - Phone:281-430-4945
Mailing Address - Fax:281-430-4225
Practice Address - Street 1:9505 NORTHPOINTE BLVD
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-3799
Practice Address - Country:US
Practice Address - Phone:281-430-4945
Practice Address - Fax:281-430-4225
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110301225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist