Provider Demographics
NPI:1619086980
Name:HACKLE, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:HACKLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3543 65TH AVENUE CIR E
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-4117
Mailing Address - Country:US
Mailing Address - Phone:941-806-9450
Mailing Address - Fax:
Practice Address - Street 1:4630 17TH ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34235-1843
Practice Address - Country:US
Practice Address - Phone:941-487-5406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11850225X00000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1055144OtherNBCOT CERTIFICATION
FL890498700Medicaid
FLOT 11850OtherOT LICENSE