Healthcare Provider Details

I. General information

NPI: 1780802512
Provider Name (Legal Business Name): SUSAN LEE KRYDYNSKI OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W MAIN ST
FREDERICKTOWN MO
63645-1111
US

IV. Provider business mailing address

139 ROCHESTER DR
JACKSON MO
63755-7196
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-3341
  • Fax:
Mailing address:
  • Phone: 573-803-7270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number002044
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: