Provider Demographics
NPI:1780720896
Name:WAGNER, BARBARA
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:
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 1:13 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:MAYNARD
Mailing Address - State:MA
Mailing Address - Zip Code:01754-2239
Mailing Address - Country:US
Mailing Address - Phone:978-897-6961
Mailing Address - Fax:
Practice Address - Street 1:13 CHARLES ST
Practice Address - Street 2:
Practice Address - City:MAYNARD
Practice Address - State:MA
Practice Address - Zip Code:01754-2239
Practice Address - Country:US
Practice Address - Phone:978-897-6961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6308225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0703761Medicaid
MAOT0130OtherBLUE CROSS BLUE SHIELD
MABA Y69562Medicare ID - Type Unspecified