Provider Demographics
NPI:1518722016
Name:HEAVENRICH, OTIS
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:
Last Name:HEAVENRICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35218 MUDD LN
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-8337
Mailing Address - Country:US
Mailing Address - Phone:503-338-8225
Mailing Address - Fax:
Practice Address - Street 1:785 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-5947
Practice Address - Country:US
Practice Address - Phone:503-338-8225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14050779235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist