Provider Demographics
NPI:1205305414
Name:WAGGONER, KATELYN NOEL (MS OTR/L)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:NOEL
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7450 E DUNDAS LN
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:IL
Mailing Address - Zip Code:62421-2129
Mailing Address - Country:US
Mailing Address - Phone:812-929-8906
Mailing Address - Fax:
Practice Address - Street 1:7450 E DUNDAS LN
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:IL
Practice Address - Zip Code:62421-2129
Practice Address - Country:US
Practice Address - Phone:812-929-8906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056012099225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist