Provider Demographics
NPI:1215763990
Name:WAGGENER, ADAM J (OTR/L)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:J
Last Name:WAGGENER
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 WALLER AVE STE 275
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2930
Mailing Address - Country:US
Mailing Address - Phone:859-447-8600
Mailing Address - Fax:859-447-8599
Practice Address - Street 1:330 WALLER AVE STE 275
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2930
Practice Address - Country:US
Practice Address - Phone:859-447-8600
Practice Address - Fax:859-447-8599
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY294715225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7101015180Medicaid