Healthcare Provider Details

I. General information

NPI: 1053224105
Provider Name (Legal Business Name): NEUROREACH PT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 MARY LN
NORTH LIBERTY IA
52317-8710
US

IV. Provider business mailing address

1142 MARY LN
NORTH LIBERTY IA
52317-8710
US

V. Phone/Fax

Practice location:
  • Phone: 712-461-0135
  • Fax:
Mailing address:
  • Phone: 712-461-0135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JEFFERY WAGENAAR
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: PT, DPT
Phone: 712-461-0135