Provider Demographics
NPI:1841368768
Name:WAGNER, LUCILLE MARIE (PT)
Entity type:Individual
Prefix:MS
First Name:LUCILLE
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LUCILLE
Other - Middle Name:MARIE LOPEZ
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:3079 NESTALL RD
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2026
Mailing Address - Country:US
Mailing Address - Phone:949-497-8227
Mailing Address - Fax:714-841-2688
Practice Address - Street 1:17456 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5913
Practice Address - Country:US
Practice Address - Phone:714-841-2688
Practice Address - Fax:714-841-2688
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3506171100000X
CAPT6997225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14802Medicare ID - Type UnspecifiedPHYSICALTHERAPY