Healthcare Provider Details

I. General information

NPI: 1922250117
Provider Name (Legal Business Name): DEANNE FAIRLEY HEITZMAN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8766 E. HWY 69 HUMBOLDT UNIFIED SCHOOL DISTRICT # 22/580
PRESCOTT VALLEY AZ
86314
US

IV. Provider business mailing address

8766 E. HWY 69 HUMBOLDT UNIFIED SCHOOL DISTRICT # 22/550
PRESCOTT VALLEY AZ
86314
US

V. Phone/Fax

Practice location:
  • Phone: 928-759-4042
  • Fax: 928-759-4030
Mailing address:
  • Phone: 928-759-4042
  • Fax: 928-759-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0125
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: