Healthcare Provider Details

I. General information

NPI: 1033608815
Provider Name (Legal Business Name): KELLIE NICHOLE HEUBLEIN MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLIE NICHOLE DAVIS MOT, OTR/L

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 TAMAL PLZ STE 527
CORTE MADERA CA
94925-1187
US

IV. Provider business mailing address

29 JOAN AVE
NOVATO CA
94947-4120
US

V. Phone/Fax

Practice location:
  • Phone: 707-339-0651
  • Fax:
Mailing address:
  • Phone: 707-339-0651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number14266
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number14266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: