Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 252548 | OR |
NPI | 1003143009 |
---|---|
Provider Name | Miss Barbara Lynette Wagner |
First Address | Monmouth, OR 97361-1883 |
Second Address | Salem, OR 97301-2426 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/11/2009 |
Last Update Date | 11/11/2009 |