Basic Information
| Provider Information | |||||||||
| NPI: | 1932665783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANTRELL | ||||||||
| FirstName: | HALEY | ||||||||
| MiddleName: | FAIN | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 CORPORATE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | HOOVER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4232383473 | ||||||||
| Practice Location | |||||||||
| Address1: | 5310 MATT HWY STE 105 | ||||||||
| Address2: | |||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300288611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4702394255 | ||||||||
| FaxNumber: | 4704272997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2019 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT007277 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XP0200X | OT007277 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 003215873C | 05 | GA | MEDICAID |