Provider Demographics
NPI:1831495092
Name:WAGNER, RAPHAELE JACQUELINE (MS,OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:RAPHAELE
Middle Name:JACQUELINE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS,OTR/L
Other - Prefix:
Other - First Name:RAPHAELE
Other - Middle Name:
Other - Last Name:LATAILLADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,OTR/L
Mailing Address - Street 1:1131 COVERBROOK LN
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-5949
Mailing Address - Country:US
Mailing Address - Phone:954-593-5884
Mailing Address - Fax:
Practice Address - Street 1:5690 F COACH HOUSE CIRCLE
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486
Practice Address - Country:US
Practice Address - Phone:561-368-3008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10833225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty