Provider Demographics
NPI:1184070716
Name:GRACE, HEATHER LOUISE (OTR/L)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:LOUISE
Last Name:GRACE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1563 PIEDMONT RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-4625
Mailing Address - Country:US
Mailing Address - Phone:814-279-4807
Mailing Address - Fax:
Practice Address - Street 1:1563 PIEDMONT RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-4625
Practice Address - Country:US
Practice Address - Phone:814-279-4807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC012811225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA225X00000XMedicaid