Provider Demographics
NPI:1407646680
Name:WAGNER, KYLA
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 MAYFIELD RD
Mailing Address - Street 2:HMB#2 SUITE 150
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6801 MAYFIELD RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2270
Practice Address - Country:US
Practice Address - Phone:440-312-4515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-09
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT021528225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist