Provider Demographics
NPI:1891022620
Name:CORBET, HEATHER MARIE (MOTR/L)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:CORBET
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 ROSEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1110 CALL CREEK DR
Practice Address - Street 2:SUITE 7
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3072
Practice Address - Country:US
Practice Address - Phone:208-233-4660
Practice Address - Fax:208-233-4262
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID927225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist