Provider Demographics
NPI:1568828465
Name:HEESH, MANDI (COTA/L)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:
Last Name:HEESH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 TANEY AVE
Mailing Address - Street 2:APT 103
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-6618
Mailing Address - Country:US
Mailing Address - Phone:302-724-0053
Mailing Address - Fax:
Practice Address - Street 1:4323 TANEY AVE
Practice Address - Street 2:APT 103
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-6618
Practice Address - Country:US
Practice Address - Phone:302-724-0053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02143224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant