Healthcare Provider Details

I. General information

NPI: 1922162684
Provider Name (Legal Business Name): ASHLEY MARCELLO WAGUESPACK M.S., L.O.T.R.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 RIDGEFIELD RD STE C
THIBODAUX LA
70301-4399
US

IV. Provider business mailing address

1713 RIDGEFIELD RD STE C
THIBODAUX LA
70301-4399
US

V. Phone/Fax

Practice location:
  • Phone: 985-449-0944
  • Fax:
Mailing address:
  • Phone: 985-449-0944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberZ12297
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: