Healthcare Provider Details

I. General information

NPI: 1265021992
Provider Name (Legal Business Name): KRISTIAN CARLOS LLACA OTD,OTR/L, ATP,CSRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2021
Last Update Date: 01/17/2021
Certification Date: 01/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1239 NW 166TH AVE
PEMBROKE PINES FL
33028-1345
US

IV. Provider business mailing address

1239 NW 166TH AVE
PEMBROKE PINES FL
33028-1345
US

V. Phone/Fax

Practice location:
  • Phone: 305-431-0887
  • Fax:
Mailing address:
  • Phone: 305-431-0887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225CA2400X
TaxonomyAssistive Technology Practitioner Rehabilitation Counselor
License NumberOT16273
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License NumberOT16273
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code225XE1200X
TaxonomyErgonomics Occupational Therapist
License NumberOT16273
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOT16273
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberOT16273
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: