Provider Demographics
NPI:1245802313
Name:HEATON, ALEXANDRA MARIE (COTA)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:MARIE
Last Name:HEATON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:MARIE
Other - Last Name:KRUG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:407 OAK HILL RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62563-9232
Mailing Address - Country:US
Mailing Address - Phone:217-836-1249
Mailing Address - Fax:
Practice Address - Street 1:100 MARIAN PKWY
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:IL
Practice Address - Zip Code:62684-9673
Practice Address - Country:US
Practice Address - Phone:217-744-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005616224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant