Individual
JONATHAN DEWAINE WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OT
Contact information
Practice address
661 RUTHERFORD RD, GREENVILLE, SC 29609-4640
(864) 232-2442
Mailing address
661 RUTHERFORD RD, GREENVILLE, SC 29609-4640
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
4630
SC
Other
Enumeration date
07/26/2017
Last updated
07/26/2017
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