Healthcare Provider Details

I. General information

NPI: 1508425885
Provider Name (Legal Business Name): CHANTAL JOHANNA OLENCZUK OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N HILL AVE STE 302
PASADENA CA
91106-1903
US

IV. Provider business mailing address

1234 E CALIFORNIA AVE APT 219
GLENDALE CA
91206-5053
US

V. Phone/Fax

Practice location:
  • Phone: 818-237-5409
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number17160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: