Provider Demographics
NPI:1245532357
Name:HEIDI E. WIGHT
Entity type:Organization
Organization Name:HEIDI E. WIGHT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:WIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-331-1375
Mailing Address - Street 1:1805 W CITY DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-9646
Mailing Address - Country:US
Mailing Address - Phone:252-331-1375
Mailing Address - Fax:252-331-1376
Practice Address - Street 1:1805 W CITY DR
Practice Address - Street 2:SUITE G
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-9646
Practice Address - Country:US
Practice Address - Phone:252-331-1375
Practice Address - Fax:252-331-1376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
NC6978225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7302265Medicaid