Healthcare Provider Details

I. General information

NPI: 1518012376
Provider Name (Legal Business Name): MARTICA LYN HEUSLER OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 BROAD STREET RD
MANAKIN SABOT VA
23103-2213
US

IV. Provider business mailing address

812 CYPRESS CT
MANAKIN SABOT VA
23103-3154
US

V. Phone/Fax

Practice location:
  • Phone: 804-784-3514
  • Fax:
Mailing address:
  • Phone: 804-784-3806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119002716
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: