Provider Demographics
NPI:1720408818
Name:WOTASIK, HANNAH
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:WOTASIK
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 1:1374 S BURLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-2445
Mailing Address - Country:US
Mailing Address - Phone:928-310-8228
Mailing Address - Fax:
Practice Address - Street 1:1374 S BURLINGTON ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-2445
Practice Address - Country:US
Practice Address - Phone:928-310-8228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5418731385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child