Healthcare Provider Details

I. General information

NPI: 1174996367
Provider Name (Legal Business Name): ELIZABETH KATHLEEN HARES OTR/L MOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH KATHLEEN HARES OTR/ L MOT MASTERS

II. Dates (important events)

Enumeration Date: 11/10/2015
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 AUTO CENTER DR. #D
PALMDALE CA
93551
US

IV. Provider business mailing address

861 AUTO CENTER DR. #D
PALMDALE CA
93551
US

V. Phone/Fax

Practice location:
  • Phone: 661-945-7878
  • Fax: 661-945-7553
Mailing address:
  • Phone: 661-945-7878
  • Fax: 661-945-7553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number15673
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: