Provider Demographics
NPI:1104200104
Name:HIGGENBOTTOM, HEIDI MARIE (MS,OTR)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:MARIE
Last Name:HIGGENBOTTOM
Suffix:
Gender:F
Credentials:MS,OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 MANOR DR
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-2376
Mailing Address - Country:US
Mailing Address - Phone:219-730-0331
Mailing Address - Fax:
Practice Address - Street 1:1120 S CALUMET RD
Practice Address - Street 2:SUITE 3
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-3285
Practice Address - Country:US
Practice Address - Phone:219-983-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
IN31005943A225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1104200104Medicaid