Provider Demographics
NPI:1770022162
Name:BROTH, HALEYANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:HALEYANN
Middle Name:
Last Name:BROTH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 HIGHCLIFF CT
Mailing Address - Street 2:#6
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-9044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 KENSINGTON AVE
Practice Address - Street 2:#100
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5674
Practice Address - Country:US
Practice Address - Phone:406-239-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOTP-OT-LIC-4704225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics