Provider Demographics
NPI:1316211105
Name:PARK, HEATHER LEIGH (OT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEIGH
Last Name:PARK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 HOLLYWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8478
Mailing Address - Country:US
Mailing Address - Phone:505-280-6534
Mailing Address - Fax:
Practice Address - Street 1:5006 COPPER AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1301
Practice Address - Country:US
Practice Address - Phone:505-268-7988
Practice Address - Fax:505-268-8021
Is Sole Proprietor?:No
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2895225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM326556OtherMEDICARE
NM10171568Medicaid