Healthcare Provider Details

I. General information

NPI: 1083369722
Provider Name (Legal Business Name): DALTON KRENCIK OTD, OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4715 KIRBY LOOP RD
FORT PIERCE FL
34981-5345
US

IV. Provider business mailing address

1702 MARINER BAY BLVD
FORT PIERCE FL
34949-3613
US

V. Phone/Fax

Practice location:
  • Phone: 772-577-6964
  • Fax: 772-461-9954
Mailing address:
  • Phone: 772-577-6964
  • Fax: 772-461-9954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT22788
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: