Provider Demographics
NPI:1619162377
Name:VANDOORN, HEATHER MARIE (COTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:VANDOORN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 COLLEGE AVE W
Mailing Address - Street 2:
Mailing Address - City:LADYSMITH
Mailing Address - State:WI
Mailing Address - Zip Code:54848-2116
Mailing Address - Country:US
Mailing Address - Phone:715-532-5561
Mailing Address - Fax:715-532-9809
Practice Address - Street 1:900 COLLEGE AVE W
Practice Address - Street 2:
Practice Address - City:LADYSMITH
Practice Address - State:WI
Practice Address - Zip Code:54848-2116
Practice Address - Country:US
Practice Address - Phone:715-532-5561
Practice Address - Fax:715-532-9809
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4567-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
4567-027OtherSTATE LICENSE