Provider Demographics
NPI:1730214073
Name:HAFICS, DYNEEN L (COTA)
Entity type:Individual
Prefix:MRS
First Name:DYNEEN
Middle Name:L
Last Name:HAFICS
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 1:200 MAIN AVE S
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-1518
Mailing Address - Country:US
Mailing Address - Phone:218-732-0868
Mailing Address - Fax:218-732-8502
Practice Address - Street 1:200 MAIN AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1518
Practice Address - Country:US
Practice Address - Phone:218-732-0868
Practice Address - Fax:218-732-8502
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN200107224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6G065PAOtherBLUE CROSS
MN6G065PAOtherBLUE CROSS