Provider Demographics
NPI:1427176015
Name:WAGNER, LEIGH (DPT)
Entity type:Individual
Prefix:MS
First Name:LEIGH
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-8930
Mailing Address - Fax:423-254-5217
Practice Address - Street 1:9039 US HIGHWAY 42 STE G
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:KY
Practice Address - Zip Code:41091-7195
Practice Address - Country:US
Practice Address - Phone:859-384-0367
Practice Address - Fax:859-384-0787
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT010238225100000X
KY005662225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK089430Medicare PIN