Provider Demographics
NPI:1497875645
Name:VINES-DUBOSE, HEATHER DUPREE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:DUPREE
Last Name:VINES-DUBOSE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1949
Mailing Address - Country:US
Mailing Address - Phone:203-979-0010
Mailing Address - Fax:
Practice Address - Street 1:698 WEST AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3302
Practice Address - Country:US
Practice Address - Phone:203-852-3400
Practice Address - Fax:203-852-3418
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002169225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation