Basic Information
| Provider Information | |||||||||
| NPI: | 1366756611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13123 E 16TH AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800457106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7207771234 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8540 SCARBOROUGH DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195970822 | ||||||||
| FaxNumber: | 7195994606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2010 | ||||||||
| LastUpdateDate: | 02/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | OT-2570 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
No ID Information.