Provider Demographics
NPI:1306268057
Name:WAGNER, MINDY (OTR/L)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
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 1:401 CRYSTAL PL
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-6219
Mailing Address - Country:US
Mailing Address - Phone:562-310-9257
Mailing Address - Fax:
Practice Address - Street 1:401 CRYSTAL PL
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-6219
Practice Address - Country:US
Practice Address - Phone:562-310-9257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9000225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics