Provider Demographics
NPI:1831340850
Name:WAGNER, MICHELLE IV
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WAGNER
Suffix:IV
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21800 CHARDON RD
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-2125
Mailing Address - Country:US
Mailing Address - Phone:216-481-9159
Mailing Address - Fax:
Practice Address - Street 1:21800 CHARDON RD
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44117-2125
Practice Address - Country:US
Practice Address - Phone:216-481-9159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-6053225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist