Basic Information
| Provider Information | |||||||||
| NPI: | 1639408057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HATFIELD | ||||||||
| FirstName: | HALEY | ||||||||
| MiddleName: | LAYNE | ||||||||
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| Credential: | MOT, OTR, MA, BCBA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BAKER | ||||||||
| OtherFirstName: | HALEY | ||||||||
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| OtherCredential: | OTR | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BOULEVARD | ||||||||
| Address2: | SUITE 3070 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 7654506664 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 N UNION STREET | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469012907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652520530 | ||||||||
| FaxNumber: | 7654506664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2009 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31004776A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 225XP0200X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1-14-15211 | 01 | BCBA CERTIFICATE | OTHER | 201225780 | 05 | IN | MEDICAID |