Provider Demographics
NPI:1265956239
Name:WAGNER, CHERYL LYNN
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 RAPP RD
Mailing Address - Street 2:ADVANCED THERAPY
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203
Mailing Address - Country:US
Mailing Address - Phone:518-867-3061
Mailing Address - Fax:
Practice Address - Street 1:300 WREN ST
Practice Address - Street 2:SACANDAGA SCHOOL
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302
Practice Address - Country:US
Practice Address - Phone:518-386-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist