Provider Demographics
NPI:1952534521
Name:WAGNER, LISA MARIE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 GLENRAY CT
Mailing Address - Street 2:
Mailing Address - City:NEW FREEDOM
Mailing Address - State:PA
Mailing Address - Zip Code:17349-8734
Mailing Address - Country:US
Mailing Address - Phone:717-235-1277
Mailing Address - Fax:410-296-6745
Practice Address - Street 1:2830 CAROL RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-3852
Practice Address - Country:US
Practice Address - Phone:865-531-2204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC004200L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist