Provider Demographics
NPI:1922785948
Name:SMRCKA, KRISTINA (OTRL)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:SMRCKA
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 1:21807 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1337
Mailing Address - Country:US
Mailing Address - Phone:734-301-0591
Mailing Address - Fax:
Practice Address - Street 1:18101 OAKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4089
Practice Address - Country:US
Practice Address - Phone:313-593-7728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201012674225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist