Provider Demographics
NPI:1952862559
Name:AGTUCA, RACHEL M
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:M
Last Name:AGTUCA
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 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:762-685-4340
Mailing Address - Fax:407-588-6294
Practice Address - Street 1:1237 AUGUSTA WEST PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1807
Practice Address - Country:US
Practice Address - Phone:762-685-4340
Practice Address - Fax:762-585-9965
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA67298101103K00000X
GA1-23-67564103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst