Provider Demographics
NPI:1891375093
Name:KRENCIK, SUSAN L (LMT)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:L
Last Name:KRENCIK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E. MAIN STREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2982
Mailing Address - Country:US
Mailing Address - Phone:631-452-2600
Mailing Address - Fax:631-425-3098
Practice Address - Street 1:202 E. MAIN STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2982
Practice Address - Country:US
Practice Address - Phone:631-452-2600
Practice Address - Fax:631-425-3098
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017561-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist