Provider Demographics
NPI:1285146167
Name:ELLISON, HALEY BROOKE (COTA/L)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:BROOKE
Last Name:ELLISON
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 1:12601 QUARTZ PL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-5467
Mailing Address - Country:US
Mailing Address - Phone:405-922-5998
Mailing Address - Fax:
Practice Address - Street 1:5301 N BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3516
Practice Address - Country:US
Practice Address - Phone:405-601-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1736224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant