Provider Demographics
NPI:1275881948
Name:ROESE, HEATHER (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:ROESE
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 53278
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92517-4278
Mailing Address - Country:US
Mailing Address - Phone:951-990-3115
Mailing Address - Fax:
Practice Address - Street 1:118 E BLAINE ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-3226
Practice Address - Country:US
Practice Address - Phone:951-990-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11998225XP0200X
OT 11998225X00000X
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
CAOT 11998OtherOT LICENSE