Provider Demographics
NPI:1447505896
Name:DELA CRUZ, FERNANDO BAUTISTA (OTL)
Entity type:Individual
Prefix:MR
First Name:FERNANDO
Middle Name:BAUTISTA
Last Name:DELA CRUZ
Suffix:
Gender:M
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 OLD BRUCEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-3889
Mailing Address - Country:US
Mailing Address - Phone:812-886-4677
Mailing Address - Fax:
Practice Address - Street 1:3801 OLD BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-3889
Practice Address - Country:US
Practice Address - Phone:812-886-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002819A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist