Provider Demographics
NPI:1407195084
Name:HAFER, MYRA (COTA/L)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:HAFER
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 1:9201 LEHALL SQ E
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-1412
Mailing Address - Country:US
Mailing Address - Phone:863-224-8585
Mailing Address - Fax:
Practice Address - Street 1:9201 LEHALL SQ E
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-1412
Practice Address - Country:US
Practice Address - Phone:863-224-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-02
Last Update Date:2013-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA12670224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant