Basic Information
Provider Information | |||||||||
NPI: | 1528438108 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WATKINS | ||||||||
FirstName: | HALEY | ||||||||
MiddleName: | ELISE TUCKER | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR/L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TUCKER | ||||||||
OtherFirstName: | HALEY | ||||||||
OtherMiddleName: | ELISE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1100 BLYTHE BLVD | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282035814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7043554645 | ||||||||
FaxNumber: | 7043554541 | ||||||||
Practice Location | |||||||||
Address1: | 561 N POLK ST | ||||||||
Address2: |   | ||||||||
City: | PINEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 281348563 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7046678470 | ||||||||
FaxNumber: | 7046678471 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2015 | ||||||||
LastUpdateDate: | 09/25/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | 9991 | NC | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
No ID Information.