Provider Demographics
NPI:1841364999
Name:WAGNER, RACHELLE (OTRL)
Entity type:Individual
Prefix:MS
First Name:RACHELLE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 GREATWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WHITE
Mailing Address - State:GA
Mailing Address - Zip Code:30184-2893
Mailing Address - Country:US
Mailing Address - Phone:706-378-9044
Mailing Address - Fax:706-378-9046
Practice Address - Street 1:304 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6000
Practice Address - Country:US
Practice Address - Phone:706-378-9044
Practice Address - Fax:706-378-9046
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003702171W00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171W00000XOther Service ProvidersContractor
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10047143Medicaid
GA342685Medicaid
GA52038467OtherBLUE CROSS BLUE SHIELD