Provider Demographics
NPI:1609400845
Name:HANEY, CAROLYN (COTA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:HANEY
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 1:5227 W WAHNER AVE
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53223-3041
Mailing Address - Country:US
Mailing Address - Phone:414-460-0837
Mailing Address - Fax:
Practice Address - Street 1:677 E STATE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1639
Practice Address - Country:US
Practice Address - Phone:262-763-9531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5662224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant