Provider Demographics
NPI:1457688715
Name:HAVNER, REBECCA J (COTA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:HAVNER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO DRAWER 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:
Practice Address - Street 1:1301 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-4320
Practice Address - Country:US
Practice Address - Phone:479-967-2322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-06
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOTA0000001644224Z00000X
AROT-A582224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1457688715Medicaid