Provider Demographics
NPI:1083868038
Name:TAGUE, HEATHER ANN (OTR)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:TAGUE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 SUNSET LN APT 10
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-1140
Mailing Address - Country:US
Mailing Address - Phone:608-383-1330
Mailing Address - Fax:
Practice Address - Street 1:860 SUNSET LN APT 10
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-1140
Practice Address - Country:US
Practice Address - Phone:608-383-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5910-26225X00000X
WI4618-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant