Healthcare Provider Details

I. General information

NPI: 1245116722
Provider Name (Legal Business Name): HEIDI LAINE FACKLAM OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 W MCCABE ST
STRAFFORD MO
65757-8840
US

IV. Provider business mailing address

702 S EASTRIDGE
NIXA MO
65714-7805
US

V. Phone/Fax

Practice location:
  • Phone: 417-736-7000
  • Fax:
Mailing address:
  • Phone: 417-350-8760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2024009426
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: