Provider Demographics
NPI:1174911010
Name:HAIRE, DONNA JO (COTA)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:JO
Last Name:HAIRE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 S BAXTER AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2209
Mailing Address - Country:US
Mailing Address - Phone:903-595-4668
Mailing Address - Fax:
Practice Address - Street 1:930 S BAXTER AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2209
Practice Address - Country:US
Practice Address - Phone:903-595-4668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210973225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001025984Medicaid
TX001025984Medicaid