Provider Demographics
NPI:1366158396
Name:TALLEDO, HEATHER ANNE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANNE
Last Name:TALLEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ANNE
Other - Last Name:KINGSBURY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WEATOGUE
Mailing Address - State:CT
Mailing Address - Zip Code:06089-9721
Mailing Address - Country:US
Mailing Address - Phone:860-985-8885
Mailing Address - Fax:
Practice Address - Street 1:142 COOPER AVE
Practice Address - Street 2:
Practice Address - City:WEATOGUE
Practice Address - State:CT
Practice Address - Zip Code:06089-7957
Practice Address - Country:US
Practice Address - Phone:860-317-0436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002711225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist