Provider Demographics
NPI:1255761342
Name:JOSE, HEATHER (OTR)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:JOSE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1079 EL CAMINO GRANDE
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:MI
Mailing Address - Zip Code:48893-9671
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1524 PORTABELLA TRL
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-4006
Practice Address - Country:US
Practice Address - Phone:989-772-2967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201002575225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist