MEDICARE: STACI DELANE HAYNES COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	334804	LA
2	224Z00000X	Occupational Therapy Assistant	217133	TX

General Provider Information

NPI Number	:	1225869266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACI DELANE HAYNES COTA/L

Provider Business Mailing Address
First Line	:	17401 W LAKE HOUSTON PKWY APT 9307
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77346-5150
Country	:	US
Telephone Number	:	318-505-4010
Fax Number	:

Provider Business Practice Location Address
First Line	:	6005 WESTVIEW DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77055-5419
Country	:	US
Telephone Number	:	713-696-0771
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2024
Last Update Date	:	08/12/2024

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