Healthcare Provider Details

I. General information

NPI: 1497875645
Provider Name (Legal Business Name): HEATHER DUPREE VINES-DUBOSE OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 WEST AVE
NORWALK CT
06850-3302
US

IV. Provider business mailing address

543 LAKESIDE DR
BRIDGEPORT CT
06606-1949
US

V. Phone/Fax

Practice location:
  • Phone: 203-852-3400
  • Fax: 203-852-3418
Mailing address:
  • Phone: 203-979-0010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number002169
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: