Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 5201008500 | MI |
NPI | 1003392044 |
---|---|
Provider Name | Ms. Elizabeth Bailey Wagner |
First Address | Kalamazoo, MI 49009-8923 |
Second Address | Kalamazoo, MI 49009-5951 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2018 |
Last Update Date | 12/07/2018 |