Provider Demographics
NPI:1174806806
Name:LEE, RACHELLE ANGELINA (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:RACHELLE
Middle Name:ANGELINA
Last Name:LEE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:RACHELLE
Other - Middle Name:ANGELINA
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1346 30TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-1933
Mailing Address - Country:US
Mailing Address - Phone:239-851-2475
Mailing Address - Fax:
Practice Address - Street 1:880 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4827
Practice Address - Country:US
Practice Address - Phone:727-767-4257
Practice Address - Fax:727-767-8847
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT14823225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004611500Medicaid