MEDICARE: ALISHIA ELLIS HEASTON OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	2905	TN

General Provider Information

NPI Number	:	1548695430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISHIA ELLIS HEASTON OTR/L

Provider Business Mailing Address
First Line	:	4603 CRADDLE HILL DR APT 206
Second Line	:
City	:	BARTLETT
State	:	TN
Zip	:	38002-1501
Country	:	US
Telephone Number	:	901-487-2039
Fax Number	:

Provider Business Practice Location Address
First Line	:	4603 CRADDLE HILL DR
Second Line	:
City	:	BARTLETT
State	:	TN
Zip	:	38002-1501
Country	:	US
Telephone Number	:	901-487-2039
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2013
Last Update Date	:	06/14/2020

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