Provider Demographics
NPI:1740701614
Name:HEATON, GAYLENE (OT-SC)
Entity type:Individual
Prefix:
First Name:GAYLENE
Middle Name:
Last Name:HEATON
Suffix:
Gender:F
Credentials:OT-SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14337N STATELINE RD
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54534
Mailing Address - Country:US
Mailing Address - Phone:715-360-1250
Mailing Address - Fax:
Practice Address - Street 1:502 COPPER ST STE 5
Practice Address - Street 2:
Practice Address - City:HURLEY
Practice Address - State:WI
Practice Address - Zip Code:54534-1386
Practice Address - Country:US
Practice Address - Phone:715-563-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16-1140246ZX2200X
17-2770246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant