Provider Demographics
NPI:1801269543
Name:WAGNER, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
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 1:35 EXECUTIVE DR STE 5
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4881
Mailing Address - Country:US
Mailing Address - Phone:765-446-8300
Mailing Address - Fax:
Practice Address - Street 1:4754 W 50 N
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-8557
Practice Address - Country:US
Practice Address - Phone:219-863-3787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
IN31006833A225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program