Provider Demographics
NPI:1124296553
Name:PENCEK, RAE K (OTR/L)
Entity type:Individual
Prefix:
First Name:RAE
Middle Name:K
Last Name:PENCEK
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 1:3595 CANTON RD
Mailing Address - Street 2:SUITE A9 321
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2658
Mailing Address - Country:US
Mailing Address - Phone:770-345-2804
Mailing Address - Fax:678-827-0927
Practice Address - Street 1:3595 CANTON RD
Practice Address - Street 2:SUITE A9 321
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-2658
Practice Address - Country:US
Practice Address - Phone:770-345-2804
Practice Address - Fax:678-827-0927
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003297225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics