MEDICARE: TAMARA D WAGNER OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	104360	TX

General Provider Information

NPI Number	:	1528254778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA D WAGNER OTR

Provider Business Mailing Address
First Line	:	3716 LAKE COUNTRY DR
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76210-3305
Country	:	US
Telephone Number	:	940-390-4000
Fax Number	:	940-535-1147

Provider Business Practice Location Address
First Line	:	3716 LAKE COUNTRY DR
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76210-3305
Country	:	US
Telephone Number	:	940-390-4000
Fax Number	:	940-535-1147

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2007
Last Update Date	:	09/21/2007

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Directions to “ TAMARA D WAGNER OTR” Practice Location

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