Provider Demographics
NPI:1396364790
Name:AGMON, RAQUEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:AGMON
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 1:6821 TEXHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE BALBOA
Mailing Address - State:CA
Mailing Address - Zip Code:91406-4345
Mailing Address - Country:US
Mailing Address - Phone:818-387-5884
Mailing Address - Fax:
Practice Address - Street 1:6821 TEXHOMA AVE
Practice Address - Street 2:
Practice Address - City:LAKE BALBOA
Practice Address - State:CA
Practice Address - Zip Code:91406-4345
Practice Address - Country:US
Practice Address - Phone:818-387-5884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20968225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist