Provider Demographics
NPI:1083369722
Name:KRENCIK, DALTON (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:DALTON
Middle Name:
Last Name:KRENCIK
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 MARINER BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34949-3613
Mailing Address - Country:US
Mailing Address - Phone:772-577-6964
Mailing Address - Fax:772-461-9954
Practice Address - Street 1:4715 KIRBY LOOP RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-5345
Practice Address - Country:US
Practice Address - Phone:772-577-6964
Practice Address - Fax:772-461-9954
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT22788225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT22788OtherFLORIDA DEPARTMENT OF HEALTH STATE LICENSE NUMBER