Healthcare Provider Details

I. General information

NPI: 1114391307
Provider Name (Legal Business Name): THERESE ANN WENGLER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2015
Last Update Date: 11/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 NILES AVENUE
SAINT PAUL MN
55116
US

IV. Provider business mailing address

1206 NILES AVENUE
SAINT PAUL MN
55116
US

V. Phone/Fax

Practice location:
  • Phone: 651-434-1558
  • Fax:
Mailing address:
  • Phone: 651-434-1558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number105019
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: