Provider Demographics
NPI:1982974200
Name:HEINZ, STEPHANIE (MOT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:HEINZ
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BIRCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4134
Mailing Address - Country:US
Mailing Address - Phone:917-902-1663
Mailing Address - Fax:
Practice Address - Street 1:99 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-1352
Practice Address - Country:US
Practice Address - Phone:718-979-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017092225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist