Provider Demographics
NPI:1992861868
Name:MARTIN, HEATHER MICHELLE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MICHELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:MICHELLE
Other - Last Name:DOLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10500 W LOOMIS RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8111
Mailing Address - Country:US
Mailing Address - Phone:414-858-9223
Mailing Address - Fax:414-858-1017
Practice Address - Street 1:10500 W LOOMIS RD
Practice Address - Street 2:SUITE 150
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8111
Practice Address - Country:US
Practice Address - Phone:414-858-9223
Practice Address - Fax:414-858-1017
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4395026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4395-026OtherLICENSE
WI41055800Medicaid