Provider Demographics
NPI:1205957743
Name:WAGNER-SMITH, DEBORAH ANN (PT)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ANN
Last Name:WAGNER-SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-8974
Mailing Address - Country:US
Mailing Address - Phone:570-587-9061
Mailing Address - Fax:
Practice Address - Street 1:915 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:PA
Practice Address - Zip Code:18421-1005
Practice Address - Country:US
Practice Address - Phone:570-785-3390
Practice Address - Fax:570-785-3937
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003965L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist