Healthcare Provider Details

I. General information

NPI: 1245532357
Provider Name (Legal Business Name): HEIDI E. WIGHT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 W CITY DR SUITE G
ELIZABETH CITY NC
27909-9646
US

IV. Provider business mailing address

1805 W CITY DR SUITE G
ELIZABETH CITY NC
27909-9646
US

V. Phone/Fax

Practice location:
  • Phone: 252-331-1375
  • Fax: 252-331-1376
Mailing address:
  • Phone: 252-331-1375
  • Fax: 252-331-1376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number6978
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JAMES ARTHUR WIGHT
Title or Position: OFFICE MANAGER
Credential:
Phone: 252-331-1375