Provider Demographics
NPI:1811751613
Name:GADDIS, RACQUEL
Entity type:Individual
Prefix:
First Name:RACQUEL
Middle Name:
Last Name:GADDIS
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 1:224 SILVER LK
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-5079
Mailing Address - Country:US
Mailing Address - Phone:601-941-8323
Mailing Address - Fax:
Practice Address - Street 1:224 SILVER LK
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-5079
Practice Address - Country:US
Practice Address - Phone:601-941-8323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOTA-2366224ZF0002X, 224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No224ZF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantFeeding, Eating & Swallowing