Healthcare Provider Details

I. General information

NPI: 1750713020
Provider Name (Legal Business Name): DIANA TERESA WAGNER MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 OLD SCHUYLKILL RD
POTTSTOWN PA
19465-7971
US

IV. Provider business mailing address

30 OLD SCHUYLKILL RD
POTTSTOWN PA
19465-7971
US

V. Phone/Fax

Practice location:
  • Phone: 610-705-3737
  • Fax: 484-624-5985
Mailing address:
  • Phone: 610-705-3737
  • Fax: 484-624-5985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT008968L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: