Provider Demographics
NPI:1902044589
Name:GRIFFIN, HEATHER MICHELE (OT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELE
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 E STEPHENS ST
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-1836
Mailing Address - Country:US
Mailing Address - Phone:229-336-5284
Mailing Address - Fax:
Practice Address - Street 1:90 E STEPHENS ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1836
Practice Address - Country:US
Practice Address - Phone:229-336-5284
Practice Address - Fax:229-336-5878
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004556225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT004556OtherLICENSE