MEDICARE: MRS. HEATHER BOSS ROACH OT

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	004268	GA

General Provider Information

NPI Number	:	1861552804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HEATHER BOSS ROACH OT

Provider Business Mailing Address
First Line	:	2810 LAKE CT
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30041-5208
Country	:	US
Telephone Number	:	770-205-0656
Fax Number	:

Provider Business Practice Location Address
First Line	:	2810 LAKE CT
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30041-5208
Country	:	US
Telephone Number	:	770-205-0656
Fax Number	:

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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