Provider Demographics
NPI:1245116722
Name:FACKLAM, HEIDI LAINE (OTR/L)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:LAINE
Last Name:FACKLAM
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 1:702 S EASTRIDGE
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7805
Mailing Address - Country:US
Mailing Address - Phone:417-350-8760
Mailing Address - Fax:
Practice Address - Street 1:218 W MCCABE ST
Practice Address - Street 2:
Practice Address - City:STRAFFORD
Practice Address - State:MO
Practice Address - Zip Code:65757-8840
Practice Address - Country:US
Practice Address - Phone:417-736-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024009426225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist