Provider Demographics
NPI:1841986817
Name:WAGNER, MICHELLE DAWN (OT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DAWN
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 1:141 HAZEL DR
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-3113
Mailing Address - Country:US
Mailing Address - Phone:607-953-1361
Mailing Address - Fax:
Practice Address - Street 1:2335 E SAUNDERS ST # 3
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-5434
Practice Address - Country:US
Practice Address - Phone:956-717-0441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012502225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics