Healthcare Provider Details

I. General information

NPI: 1124377833
Provider Name (Legal Business Name): KELLY HEFTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 S 102ND ST SUITE 340
MILWAUKEE WI
53227-2466
US

IV. Provider business mailing address

409 WILSON ST
PLYMOUTH WI
53073-1053
US

V. Phone/Fax

Practice location:
  • Phone: 414-329-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4833-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: