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General NPI Number Information
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NPI Number | 1245116722
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Entity Type | Individual
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Provider Name | HEIDI LAINE FACKLAM OTR/L
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Gender | Female
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Dates
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Enumeration Date | 08/12/2025
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Last Update Date | 08/12/2025
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Provider Practice Location Address
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Address Line | 218 W MCCABE ST
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City | STRAFFORD
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State | MO
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Zip | 65757-8840
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Country | US
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Telephone | 417-736-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 702 S EASTRIDGE
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City | NIXA
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State | MO
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Zip | 65714-7805
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Country | US
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Telephone | 417-350-8760
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 2024009426
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License Number State | MO
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