Provider Demographics
NPI:1871879452
Name:WAGNER, KATHLEEN MARIE (COTA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 WESTON ST
Mailing Address - Street 2:
Mailing Address - City:PEA RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72751-2628
Mailing Address - Country:US
Mailing Address - Phone:479-451-8181
Mailing Address - Fax:
Practice Address - Street 1:979 WESTON ST
Practice Address - Street 2:
Practice Address - City:PEA RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72751-2628
Practice Address - Country:US
Practice Address - Phone:479-451-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A625224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR186686721Medicaid