Provider Demographics
NPI:1619325933
Name:MANNING, HEATHER (COTA/L)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MANNING
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 1:1220 MONTANA ST
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-1856
Mailing Address - Country:US
Mailing Address - Phone:208-934-5601
Mailing Address - Fax:
Practice Address - Street 1:1220 MONTANA ST
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-1856
Practice Address - Country:US
Practice Address - Phone:208-934-5601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1605224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant