Provider Demographics
NPI:1043735178
Name:WANG, HEIDI MELLOR (MOTR/L)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:MELLOR
Last Name:WANG
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:PO BOX 3192
Mailing Address - Street 2:
Mailing Address - City:RUNNING SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92382-3192
Mailing Address - Country:US
Mailing Address - Phone:909-936-9202
Mailing Address - Fax:
Practice Address - Street 1:1323 W COLTON AVE STE 105
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2853
Practice Address - Country:US
Practice Address - Phone:909-936-9202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT17277225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist