Healthcare Provider Details

I. General information

NPI: 1306268057
Provider Name (Legal Business Name): MINDY WAGNER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CRYSTAL PL
SEAL BEACH CA
90740-6219
US

IV. Provider business mailing address

401 CRYSTAL PL
SEAL BEACH CA
90740-6219
US

V. Phone/Fax

Practice location:
  • Phone: 562-310-9257
  • Fax:
Mailing address:
  • Phone: 562-310-9257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number9000
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: