Healthcare Provider Details

I. General information

NPI: 1154244697
Provider Name (Legal Business Name): GRACE BAGWELL OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1738 THOMASVILLE RD
TALLAHASSEE FL
32303-5754
US

IV. Provider business mailing address

3465 LENOX MILL RD
TALLAHASSEE FL
32309-6832
US

V. Phone/Fax

Practice location:
  • Phone: 850-909-5521
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT27294
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: