Healthcare Provider Details

I. General information

NPI: 1528394046
Provider Name (Legal Business Name): MELISSA BROOKE WAGANER MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

REGIONAL THERAPY SERVICES 2510 W HUDSON RD
ROGERS AR
72756
US

IV. Provider business mailing address

REGIONAL THERAPY SERVICES 2510 W HUDSON RD
ROGERS AR
72756
US

V. Phone/Fax

Practice location:
  • Phone: 479-936-1061
  • Fax: 855-812-1132
Mailing address:
  • Phone: 803-795-9292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTR3392
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: