Healthcare Provider Details

I. General information

NPI: 1508914144
Provider Name (Legal Business Name): MONICA AVILA HEITMANN O.T.L.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 11/30/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 MISSION AVE
SAN RAFAEL CA
94901-6106
US

IV. Provider business mailing address

2925 SPRING CREEK DR
SANTA ROSA CA
95405-7036
US

V. Phone/Fax

Practice location:
  • Phone: 415-456-9350
  • Fax: 415-456-1508
Mailing address:
  • Phone: 415-608-2306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number9035
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: