Provider Demographics
NPI:1316207442
Name:OTTO, HALLEY M (PT)
Entity Type:Individual
Prefix:
First Name:HALLEY
Middle Name:M
Last Name:OTTO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:HALLEY
Other - Middle Name:M
Other - Last Name:SPARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 470
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568-0470
Mailing Address - Country:US
Mailing Address - Phone:715-356-8870
Mailing Address - Fax:715-356-8079
Practice Address - Street 1:240 MAPLE ST
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-9190
Practice Address - Country:US
Practice Address - Phone:715-356-8870
Practice Address - Fax:715-356-8079
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11949225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1316207442Medicaid