Healthcare Provider Details

I. General information

NPI: 1124296553
Provider Name (Legal Business Name): RAE K. PENCEK OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3595 CANTON RD SUITE A9 321
MARIETTA GA
30066-2658
US

IV. Provider business mailing address

3595 CANTON RD SUITE A9 321
MARIETTA GA
30066-2658
US

V. Phone/Fax

Practice location:
  • Phone: 770-345-2804
  • Fax: 678-827-0927
Mailing address:
  • Phone: 770-345-2804
  • Fax: 678-827-0927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT003297
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: