Provider Demographics
NPI:1922162684
Name:WAGUESPACK, ASHLEY MARCELLO (MS, LOTR)
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:MARCELLO
Last Name:WAGUESPACK
Suffix:
Gender:F
Credentials:MS, LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 RIDGEFIELD RD STE C
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4399
Mailing Address - Country:US
Mailing Address - Phone:985-449-0944
Mailing Address - Fax:
Practice Address - Street 1:1713 RIDGEFIELD RD STE C
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4399
Practice Address - Country:US
Practice Address - Phone:985-449-0944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ12297225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist