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Individual

LISA WAGNER

Active
Sole proprietor
No

Provider details

NPI number
Gender
F

Contact information

Practice address
477 CONNECTICUT BLVD, STE 200, EAST HARTFORD, CT 06108-3268
(860) 289-6021
Mailing address
76 GRANDE RD, EAST HARTFORD, CT 06118-2044
(860) 568-3244

Taxonomy

Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
000858
LICENSE #
CT
Enumeration date
08/30/2006
Last updated
07/08/2007
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