Basic Information
| Provider Information | |||||||||
| NPI: | 1497951305 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1665 HACKNEY RD | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457158700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405589904 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457502024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403761084 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA05723 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.