Provider Demographics
NPI:1992064752
Name:WACKER, AUTUMN ROSE (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ROSE
Last Name:WACKER
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38416 MORRISONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOVETTSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20180-3102
Mailing Address - Country:US
Mailing Address - Phone:703-298-5319
Mailing Address - Fax:
Practice Address - Street 1:38416 MORRISONVILLE RD
Practice Address - Street 2:
Practice Address - City:LOVETTSVILLE
Practice Address - State:VA
Practice Address - Zip Code:20180-3102
Practice Address - Country:US
Practice Address - Phone:703-298-5319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005637225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist