Healthcare Provider Details

I. General information

NPI: 1639578644
Provider Name (Legal Business Name): MRS. JOAN WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N MILLER RD BLDG 150
FAIRLAWN OH
44333-3770
US

IV. Provider business mailing address

260 BROOK VIEW DR
CUYAHOGA FALLS OH
44223-3533
US

V. Phone/Fax

Practice location:
  • Phone: 330-630-1860
  • Fax:
Mailing address:
  • Phone: 330-815-1514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA0853
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: