Provider Demographics
NPI:1528254778
Name:WAGNER, TAMARA D (OTR)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3716 LAKE COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-3305
Mailing Address - Country:US
Mailing Address - Phone:940-390-4000
Mailing Address - Fax:940-535-1147
Practice Address - Street 1:3716 LAKE COUNTRY DR
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-3305
Practice Address - Country:US
Practice Address - Phone:940-390-4000
Practice Address - Fax:940-535-1147
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104360225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist