Provider Demographics
NPI:1376567792
Name:MACDONALD, AGATA S (OTR/L)
Entity Type:Individual
Prefix:
First Name:AGATA
Middle Name:S
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1473 GULF WINDS DR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-1929
Mailing Address - Country:US
Mailing Address - Phone:850-932-2673
Mailing Address - Fax:
Practice Address - Street 1:4 JACKSON ST NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4925
Practice Address - Country:US
Practice Address - Phone:850-862-7227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 9614225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist