Healthcare Provider Details

I. General information

NPI: 1780720896
Provider Name (Legal Business Name): BARBARA WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 CHARLES ST
MAYNARD MA
01754-2239
US

IV. Provider business mailing address

13 CHARLES ST
MAYNARD MA
01754-2239
US

V. Phone/Fax

Practice location:
  • Phone: 978-897-6961
  • Fax:
Mailing address:
  • Phone: 978-897-6961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6308
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: