Provider Demographics
NPI:1831311554
Name:HEIDE, SANDRA LEE (MS, OTR)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:HEIDE
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8049 W SANDS DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-2190
Mailing Address - Country:US
Mailing Address - Phone:623-225-8894
Mailing Address - Fax:
Practice Address - Street 1:8049 W SANDS DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2190
Practice Address - Country:US
Practice Address - Phone:623-225-8894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2112225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ754136OtherAHCCCS