Provider Demographics
NPI:1356153787
Name:WAGNER, HAILEY (OTR)
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6584 STATE ROUTE 1245
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:KY
Mailing Address - Zip Code:42369-9731
Mailing Address - Country:US
Mailing Address - Phone:812-598-9416
Mailing Address - Fax:
Practice Address - Street 1:529 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2923
Practice Address - Country:US
Practice Address - Phone:270-807-0316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY296345225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist