=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518201060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KATHRYN A. HEISE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2012
-----------------------------------------------------
Last Update Date | 11/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1855 SE 51ST TER
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34480-5763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-694-1178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1855 SE 51ST TER
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34480-5763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST ASSIT.
-----------------------------------------------------
Name | MRS. KATHRYN ANN HEISE
-----------------------------------------------------
Credential | COTA
-----------------------------------------------------
Telephone | 352-694-1178
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | OTA224Z00000X
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------