Bethany Wagenbach, PTA

Primary specialty

Physical Therapy AssistantTaxonomy code 225200000X

License

160.009110 Issued in IL

Practice address

6809 N Knoxville Ave
Peoria, IL 61614-2812

Phone

(309) 981-8810

NPI assigned

May 19, 2021

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

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": "1621382400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1621382400000",
    "number": "1801460266",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "507 S WARREN ST",
            "city": "TREMONT",
            "state": "IL",
            "postal_code": "615688565"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6809 N KNOXVILLE AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616142812",
            "telephone_number": "309-981-8810"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGENBACH",
        "first_name": "BETHANY",
        "credential": "PTA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-05-19",
        "last_updated": "2021-05-19",
        "certification_date": "2021-05-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "IL",
            "license": "160.009110",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Sarah Vujanov, LCSW
• Allen M Vukov, MD
• W R Smith Drug Stores Inc
• Lisa Beth Wade
• Segolene Waechter, BCBA
• Jill Louise Wagenbach, APRN-BC, CNP
• Benjamin Louis Wagner, DO
• Grace Elizabeth Wagner, DNP, APRN, CPNP
• Jenny Wagner
• Julie Wagner

• Physical Therapy Assistant in Peoria, IL
• Providers in Peoria, IL by specialty
• Physical Therapy Assistant in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 19, 2021; 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.