Healthcare Provider Details

I. General information

NPI: 1609850387
Provider Name (Legal Business Name): HEATHER MARIE TAVARES OTR L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6506 LOISDALE RD STE 300
SPRINGFIELD VA
22150
US

IV. Provider business mailing address

25893 DONOVAN DR
CHANTILLY VA
20152
US

V. Phone/Fax

Practice location:
  • Phone: 703-924-4100
  • Fax: 703-922-0638
Mailing address:
  • Phone: 703-957-4268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119003116
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT010000316
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: