Provider Demographics
NPI:1841770039
Name:UNDERWOOD, HEATHER B (OTR/L)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:B
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:B
Other - Last Name:BUGNO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:29676 N 126TH DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-2483
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11811 N TATUM BLVD STE 3031
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1621
Practice Address - Country:US
Practice Address - Phone:602-708-8091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-007549225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist