Provider Demographics
NPI:1952456568
Name:HACKLEY, PAULA JEAN IV (OTRL)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:JEAN
Last Name:HACKLEY
Suffix:IV
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 LINDEN RD APT 609
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-4103
Mailing Address - Country:US
Mailing Address - Phone:440-356-8715
Mailing Address - Fax:
Practice Address - Street 1:10011 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-4701
Practice Address - Country:US
Practice Address - Phone:216-791-8363
Practice Address - Fax:216-791-2539
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT-005746174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH340753561030OtherCARESOURCE ID