Basic Information
Provider Information | |||||||||
NPI: | 1174686075 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAKER | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS,OTR-L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SHAVER | ||||||||
OtherFirstName: | HEATHER | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS,OTR-L | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 197 PAT FARLEY RD | ||||||||
Address2: |   | ||||||||
City: | NORWICH | ||||||||
State: | NY | ||||||||
PostalCode: | 138153124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6073349826 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 95 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | SIDNEY | ||||||||
State: | NY | ||||||||
PostalCode: | 138381601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6075632135 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2006 | ||||||||
LastUpdateDate: | 09/04/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/04/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 013302-1 | NY | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.