Provider Demographics
NPI:1215471792
Name:BRISTOW, HEIDI LETICIA (OTR/L)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:LETICIA
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:BEUTEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:PO BOX 5105
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5100
Mailing Address - Country:US
Mailing Address - Phone:336-545-5000
Mailing Address - Fax:336-545-5020
Practice Address - Street 1:3200 NORTHLINE AVE STE 160
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7613
Practice Address - Country:US
Practice Address - Phone:336-545-5000
Practice Address - Fax:336-545-5020
Is Sole Proprietor?:No
Enumeration Date:2016-12-19
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8430225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8430OtherOT LICENSE