Provider Demographics
NPI:1285271759
Name:WAGNER, RIVKA (COTA)
Entity type:Individual
Prefix:
First Name:RIVKA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 ASPEN CT
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4335
Mailing Address - Country:US
Mailing Address - Phone:454-993-8238
Mailing Address - Fax:
Practice Address - Street 1:110 HILLSIDE BLVD STE 7
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-3394
Practice Address - Country:US
Practice Address - Phone:732-813-4263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00503500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist