Healthcare Provider Details

I. General information

NPI: 1851419246
Provider Name (Legal Business Name): ANGELA MAHONEY KREIDL MS OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA DENISE MAHONEY MS OTRL

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 16TH AVE N STE B
JACKSONVILLE BEACH FL
32250-4819
US

IV. Provider business mailing address

1856 TIERRA VERDE DR
ATLANTIC BEACH FL
32233-4527
US

V. Phone/Fax

Practice location:
  • Phone: 904-249-8893
  • Fax: 904-879-5707
Mailing address:
  • Phone: 508-241-4547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number21415
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: