Provider Demographics
NPI:1619457645
Name:HAILE, ANNELISE KATHRYN (COTA/L)
Entity Type:Individual
Prefix:
First Name:ANNELISE
Middle Name:KATHRYN
Last Name:HAILE
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 1:695 CLAREMONT DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-5445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 N LINCOLN ST STE A
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:CA
Practice Address - Zip Code:95620-3238
Practice Address - Country:US
Practice Address - Phone:707-366-5246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA4486224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant