Healthcare Provider Details

I. General information

NPI: 1275583544
Provider Name (Legal Business Name): CAROLE SUE WAGNER O.T.R./L
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

862 PHEASANT WOODS DR
MANCHESTER MO
63021-4300
US

V. Phone/Fax

Practice location:
  • Phone: 314-894-6505
  • Fax: 314-845-5077
Mailing address:
  • Phone: 636-394-7429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2004012994
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: