Provider Demographics
NPI:1114143740
Name:GAYLORD, HEATHER COLLEEN (OTR)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:COLLEEN
Last Name:GAYLORD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 7TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829
Mailing Address - Country:US
Mailing Address - Phone:715-822-6167
Mailing Address - Fax:
Practice Address - Street 1:1110 7TH STREET
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829
Practice Address - Country:US
Practice Address - Phone:715-822-6167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1585-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40724900Medicaid