Provider Demographics
NPI:1912006057
Name:SECREST, KRISTINE A (OTRL)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:A
Last Name:SECREST
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 BLACKWOOD AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4523
Mailing Address - Country:US
Mailing Address - Phone:407-295-8890
Mailing Address - Fax:407-295-8876
Practice Address - Street 1:1151 BLACKWOOD AVE STE 170
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4523
Practice Address - Country:US
Practice Address - Phone:407-295-8890
Practice Address - Fax:407-295-8876
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0002762225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist