Provider Demographics
NPI:1033608815
Name:HEUBLEIN, KELLIE NICHOLE (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:NICHOLE
Last Name:HEUBLEIN
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:NICHOLE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:29 JOAN AVE
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4120
Mailing Address - Country:US
Mailing Address - Phone:707-339-0651
Mailing Address - Fax:
Practice Address - Street 1:500 TAMAL PLZ STE 527
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1187
Practice Address - Country:US
Practice Address - Phone:707-339-0651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14266225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist