Basic Information
Provider Information
NPI: 1003143009
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WAGNER
FirstName: BARBARA
MiddleName: LYNETTE
NamePrefix: MISS
NameSuffix:  
Credential: MOTR/L
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1824 DENALI DR E
Address2:  
City: MONMOUTH
State: OR
PostalCode: 973611883
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 820 COTTAGE ST NE
Address2:  
City: SALEM
State: OR
PostalCode: 973012426
CountryCode: US
TelephoneNumber: 5033990202
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/11/2009
LastUpdateDate: 11/11/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225X00000X252548ORY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist 

No ID Information.


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