Provider Demographics
NPI:1104234517
Name:WAGSTAFF, AMBER (LMT, NMT)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:WAGSTAFF
Suffix:
Gender:F
Credentials:LMT, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 VALLEY VIEW PL
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-7711
Mailing Address - Country:US
Mailing Address - Phone:208-916-7971
Mailing Address - Fax:
Practice Address - Street 1:160 HERITAGE WAY STE 104
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3127
Practice Address - Country:US
Practice Address - Phone:208-916-7971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT17866225700000X
OR20500225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist