Provider Demographics
NPI:1043795115
Name:VASQUEZ, WANDA KAY (OT)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:KAY
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 S LAKE CORTEZ DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-4827
Mailing Address - Country:US
Mailing Address - Phone:615-927-2405
Mailing Address - Fax:
Practice Address - Street 1:60 N CHARLES RICHARD BEALL BLVD
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-2513
Practice Address - Country:US
Practice Address - Phone:386-668-4426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT15977225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty