Healthcare Provider Details

I. General information

NPI: 1528797040
Provider Name (Legal Business Name): KENZIE RENEE MILLER OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KENZIE SALZBRENNER

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 S 13TH ST
DECATUR IN
46733-1807
US

IV. Provider business mailing address

4251 LAHMEYER RD
FORT WAYNE IN
46815-5676
US

V. Phone/Fax

Practice location:
  • Phone: 260-702-0410
  • Fax: 260-724-7778
Mailing address:
  • Phone: 260-432-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31007726A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: