Provider Demographics
NPI:1902365505
Name:HEADD, SCHORRE JOEL (COTA/L)
Entity Type:Individual
Prefix:
First Name:SCHORRE
Middle Name:JOEL
Last Name:HEADD
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 1:4533 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-3929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4533 HARRISON ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-3929
Practice Address - Country:US
Practice Address - Phone:219-805-8782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32003264A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant