Provider Demographics
NPI:1255496816
Name:RAYNACK, HEATHER LEIGH (OTR)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEIGH
Last Name:RAYNACK
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 1:4029 SWEETBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-4310
Mailing Address - Country:US
Mailing Address - Phone:706-650-8040
Mailing Address - Fax:
Practice Address - Street 1:690 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6348
Practice Address - Country:US
Practice Address - Phone:803-648-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2361225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1039Medicaid