Provider Demographics
NPI:1104472729
Name:CHAN, LEE ANNE KRYSTLE RICO (OTR/L)
Entity type:Individual
Prefix:
First Name:LEE ANNE KRYSTLE
Middle Name:RICO
Last Name:CHAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9892 SHORE BREAK LN APT 105
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-2971
Mailing Address - Country:US
Mailing Address - Phone:917-514-4470
Mailing Address - Fax:
Practice Address - Street 1:9715 HEALTHWAY DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3500
Practice Address - Country:US
Practice Address - Phone:410-641-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-11
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC013811225X00000X
DEU1-0001898225X00000X
MD08263225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist