Provider Demographics
NPI:1639710486
Name:BRAGG, RACQUEL P (LMT MMP)
Entity Type:Individual
Prefix:MISS
First Name:RACQUEL
Middle Name:P
Last Name:BRAGG
Suffix:
Gender:F
Credentials:LMT MMP
Other - Prefix:MISS
Other - First Name:RACQUEL
Other - Middle Name:P
Other - Last Name:BRAGGMUHAMMAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT MMP
Mailing Address - Street 1:PO BOX 13714
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-0714
Mailing Address - Country:US
Mailing Address - Phone:470-446-9501
Mailing Address - Fax:
Practice Address - Street 1:5840 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4972
Practice Address - Country:US
Practice Address - Phone:470-446-9501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT011371225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist