Provider Demographics
NPI:1053691303
Name:HASELOFF, LORI HUMPHREY (MOTR/L)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:HUMPHREY
Last Name:HASELOFF
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12116 BELLA PALAZZO DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76126-2134
Mailing Address - Country:US
Mailing Address - Phone:254-717-8490
Mailing Address - Fax:
Practice Address - Street 1:5417 ALTAMESA BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-2804
Practice Address - Country:US
Practice Address - Phone:817-370-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113426225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist