Provider Demographics
NPI:1295355642
Name:WAGUESPACK, DARETH LYNN
Entity type:Individual
Prefix:
First Name:DARETH
Middle Name:LYNN
Last Name:WAGUESPACK
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 1:13058 L LANDRY RD
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-6001
Mailing Address - Country:US
Mailing Address - Phone:225-715-7551
Mailing Address - Fax:
Practice Address - Street 1:821 N BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2835
Practice Address - Country:US
Practice Address - Phone:225-939-7205
Practice Address - Fax:225-647-9503
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z12146225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist