Individual
KATHLEEN MARIE WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
979 WESTON ST, PEA RIDGE, AR 72751-2628
(479) 451-8181
Mailing address
979 WESTON ST, PEA RIDGE, AR 72751-2628
(479) 451-8181
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
OT-A625
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
186686721
—
AR
Enumeration date
10/27/2011
Last updated
10/20/2023
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