Provider Demographics
NPI:1750837316
Name:HATLEY, KLANESE KRYSTAL (COTA/L)
Entity Type:Individual
Prefix:
First Name:KLANESE
Middle Name:KRYSTAL
Last Name:HATLEY
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:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:CLIFF
Mailing Address - State:NM
Mailing Address - Zip Code:88028
Mailing Address - Country:US
Mailing Address - Phone:575-535-2499
Mailing Address - Fax:
Practice Address - Street 1:180 N. DATE STREET
Practice Address - Street 2:
Practice Address - City:T OR C
Practice Address - State:NM
Practice Address - Zip Code:87901
Practice Address - Country:US
Practice Address - Phone:575-894-8372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3565224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant