Provider Demographics
NPI:1861552804
Name:ROACH, HEATHER BOSS (OT)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:BOSS
Last Name:ROACH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 LAKE CT
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-5208
Mailing Address - Country:US
Mailing Address - Phone:770-205-0656
Mailing Address - Fax:
Practice Address - Street 1:2810 LAKE CT
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-5208
Practice Address - Country:US
Practice Address - Phone:770-205-0656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004268225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist