=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114146222
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER ANN DIBIASO OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2007
-----------------------------------------------------
Last Update Date | 11/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1715 ELLINGTON RD
-----------------------------------------------------
City | SOUTH WINDSOR
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06074-2707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-644-4408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 FERNWOOD DR
-----------------------------------------------------
City | WINDSOR LOCKS
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06096-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-614-1487
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 002612
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------