Provider Demographics
NPI:1083364962
Name:HAYNES, BRITTANY NICOLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:NICOLE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 QUARRY ST
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:IL
Mailing Address - Zip Code:62088-1328
Mailing Address - Country:US
Mailing Address - Phone:618-792-4259
Mailing Address - Fax:
Practice Address - Street 1:649 LEGACY PL
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-2050
Practice Address - Country:US
Practice Address - Phone:618-448-0206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005750224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant