Mary Wagner, COTA

Primary specialty

Occupational Therapy AssistantTaxonomy code 224Z00000X

License

5738-27 Issued in WI

Practice address

3415 Sheridan Rd
Kenosha, WI 53140-1924

Phone

(262) 657-6175

NPI assigned

Jul 7, 2022

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1657152000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1657152000000",
    "number": "1033842075",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5591 WHIRLAWAN LN",
            "city": "RACINE",
            "state": "WI",
            "postal_code": "53402"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3415 SHERIDAN RD",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531401924",
            "telephone_number": "262-657-6175"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "MARY",
        "credential": "COTA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-07-07",
        "last_updated": "2022-07-07",
        "certification_date": "2022-06-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "224Z00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Occupational Therapy Assistant",
            "state": "WI",
            "license": "5738-27",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://bay-watersedge.com",
            "affiliation": "N",
            "address_1": "3415 Sheridan Rd",
            "city": "Kenosha",
            "state": "WI",
            "country_code": "US",
            "postal_code": "531401924",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Vop Kenosha, LLC
• Garrett Vucenic, LAT
• Mark R Vytlacil, M.D.
• W E Opticians of Kenosha LTD
• Erin Wachter, LCSW
• Monica Wagner, APSW
• Shelby Wagner, M.S., CCC-SLP
• Samantha Marie Wahner
• Anna Waite
• Wal-Mart Stores East LP

• Occupational Therapy Assistant in Kenosha, WI
• Providers in Kenosha, WI by specialty
• Occupational Therapy Assistant in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 7, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.