Provider Demographics
NPI:1093369290
Name:CONKLIN, HEATHER ELIZABETH (COTA/L)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELIZABETH
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BLAKEMORE DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-7336
Mailing Address - Country:US
Mailing Address - Phone:772-485-1056
Mailing Address - Fax:
Practice Address - Street 1:15 CYPRESS BRANCH WAY STE 207D
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8414
Practice Address - Country:US
Practice Address - Phone:386-585-5955
Practice Address - Fax:386-585-7017
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17363224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant