Provider Demographics
NPI:1285767400
Name:HEVERLY, DWINELL L (BS OT)
Entity type:Individual
Prefix:
First Name:DWINELL
Middle Name:L
Last Name:HEVERLY
Suffix:
Gender:F
Credentials:BS OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WILD FLOWER RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-9667
Mailing Address - Country:US
Mailing Address - Phone:505-426-1753
Mailing Address - Fax:505-454-5702
Practice Address - Street 1:901 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3928
Practice Address - Country:US
Practice Address - Phone:505-454-5700
Practice Address - Fax:505-454-5702
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1457225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM225X00000XMedicaid