Provider Demographics
NPI:1942715461
Name:TYRA, HEATHER (MOT, OTRL)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:TYRA
Suffix:
Gender:F
Credentials:MOT, OTRL
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:DEPRIEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTRL
Mailing Address - Street 1:4756 DUDLEY ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48125-2629
Mailing Address - Country:US
Mailing Address - Phone:734-837-8925
Mailing Address - Fax:
Practice Address - Street 1:30000 HIVELEY ST
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-1089
Practice Address - Country:US
Practice Address - Phone:734-713-9293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009882225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist