Provider Demographics
NPI:1558124040
Name:HAAG, MICHAEL BRYAN (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRYAN
Last Name:HAAG
Suffix:
Gender:M
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 WAKEFIELD LN
Mailing Address - Street 2:
Mailing Address - City:AVA
Mailing Address - State:NY
Mailing Address - Zip Code:13303-1816
Mailing Address - Country:US
Mailing Address - Phone:315-570-1248
Mailing Address - Fax:
Practice Address - Street 1:2513 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5851
Practice Address - Country:US
Practice Address - Phone:315-797-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028317225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist