Provider Demographics
NPI:1609850387
Name:TAVARES, HEATHER MARIE (OTR L)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MARIE
Last Name:TAVARES
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25893 DONOVAN DR
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152
Mailing Address - Country:US
Mailing Address - Phone:703-957-4268
Mailing Address - Fax:
Practice Address - Street 1:6506 LOISDALE RD
Practice Address - Street 2:STE 300
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150
Practice Address - Country:US
Practice Address - Phone:703-924-4100
Practice Address - Fax:703-922-0638
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003116225X00000X
DCOT010000316225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist