=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063172997
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTINA LORRAINE FENSKE-VINCENT OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2021
-----------------------------------------------------
Last Update Date | 12/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 418 RAILROAD ST STE 102
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17821-1547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-360-8646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 PETERSON AVE
-----------------------------------------------------
City | SOUTH PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91030-4032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-798-3490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | OC018225
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------