Provider Demographics
NPI:1376779942
Name:WAGUESPACK, ANGELLE (OT)
Entity Type:Individual
Prefix:
First Name:ANGELLE
Middle Name:
Last Name:WAGUESPACK
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 1:7168 HIGHWAY 44
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-8121
Mailing Address - Country:US
Mailing Address - Phone:225-647-6719
Mailing Address - Fax:
Practice Address - Street 1:7168 HIGHWAY 44
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-8121
Practice Address - Country:US
Practice Address - Phone:225-647-6719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z11964225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist