Individual
MARY WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
3415 SHERIDAN RD, KENOSHA, WI 53140-1924
(262) 657-6175
Mailing address
5591 WHIRLAWAN LN, RACINE, WI 53402
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
5738-27
WI
Other
Enumeration date
07/07/2022
Last updated
07/07/2022
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