Provider Demographics
NPI:1902482953
Name:VANBROCKLIN, CRISTINA GRACE (OTR/L)
Entity Type:Individual
Prefix:
First Name:CRISTINA
Middle Name:GRACE
Last Name:VANBROCKLIN
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 1:136 WELSH DR APT A
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-2465
Mailing Address - Country:US
Mailing Address - Phone:301-526-6388
Mailing Address - Fax:
Practice Address - Street 1:555 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2250
Practice Address - Country:US
Practice Address - Phone:717-544-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-21
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOT010001821225X00000X
MD09218225X00000X
PAOC018051225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist