Individual
KELSEY WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
4754 W 50 N, RENSSELAER, IN 47978-8557
(219) 863-3787
Mailing address
35 EXECUTIVE DR STE 5, LAFAYETTE, IN 47905-4881
(765) 446-8300
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
—
—
225XP0200X
Pediatric Occupational Therapist
Primary
31006833A
IN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
11/03/2015
Last updated
07/29/2020
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