Provider Demographics
NPI:1417288689
Name:DALLAS, RAQUEL
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:DALLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2599 SHEILA DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-4819
Mailing Address - Country:US
Mailing Address - Phone:407-399-2546
Mailing Address - Fax:352-742-7837
Practice Address - Street 1:2762 DORA AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4970
Practice Address - Country:US
Practice Address - Phone:352-742-7837
Practice Address - Fax:352-742-7837
Is Sole Proprietor?:No
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12172225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist