Provider Demographics
NPI:1770209322
Name:WAGNER, RILEY ANN (OT)
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:ANN
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 1:3270 KINGSHOUSE CMNS
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-7608
Mailing Address - Country:US
Mailing Address - Phone:630-649-9190
Mailing Address - Fax:
Practice Address - Street 1:7 DUNWOODY PARK
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6711
Practice Address - Country:US
Practice Address - Phone:678-616-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT008662225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty