Provider Demographics
NPI:1063172997
Name:FENSKE-VINCENT, KRISTINA LORRAINE (OTR)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LORRAINE
Last Name:FENSKE-VINCENT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4032
Mailing Address - Country:US
Mailing Address - Phone:570-798-3490
Mailing Address - Fax:
Practice Address - Street 1:418 RAILROAD ST STE 102
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-1547
Practice Address - Country:US
Practice Address - Phone:570-360-8646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC018225225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty