Healthcare Provider Details

I. General information

NPI: 1841583713
Provider Name (Legal Business Name): DIANE MAY VAN WAGNER OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 OAK ST
CINCINNATI OH
45219-2504
US

IV. Provider business mailing address

1321 E SCOTT ST
PENSACOLA FL
32503-4656
US

V. Phone/Fax

Practice location:
  • Phone: 513-984-4909
  • Fax:
Mailing address:
  • Phone: 850-861-1138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number25588
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number7400
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: