Healthcare Provider Details

I. General information

NPI: 1083772925
Provider Name (Legal Business Name): DALE EDWARD LYNN OTRL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 NEW HARTFORD RD
OWENSBORO KY
42303-1316
US

IV. Provider business mailing address

2605 NEW HARTFORD RD
OWENSBORO KY
42303-1316
US

V. Phone/Fax

Practice location:
  • Phone: 270-688-8449
  • Fax: 270-240-4840
Mailing address:
  • Phone: 270-302-9795
  • Fax: 270-240-4840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number134498
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number134498
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: