Provider Demographics
NPI:1669967634
Name:HATTON, REBECCA CAMILLE (COTA/L)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:CAMILLE
Last Name:HATTON
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 1:401 N LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:EAST PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63845-1113
Mailing Address - Country:US
Mailing Address - Phone:573-931-5166
Mailing Address - Fax:
Practice Address - Street 1:401 N LINCOLN ST
Practice Address - Street 2:
Practice Address - City:EAST PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63845-1113
Practice Address - Country:US
Practice Address - Phone:573-931-5166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018013044224Z00000X
TX215172224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO22Medicaid