Provider Demographics
NPI:1053007849
Name:MAIN, HEATHER L (ADMINISTRATOR, OWNER)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:MAIN
Suffix:
Gender:F
Credentials:ADMINISTRATOR, OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10144 E CINTRON DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-9579
Mailing Address - Country:US
Mailing Address - Phone:480-276-9113
Mailing Address - Fax:480-573-2169
Practice Address - Street 1:1910 S STAPLEY DR STE 221
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6680
Practice Address - Country:US
Practice Address - Phone:480-573-2269
Practice Address - Fax:480-573-2169
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator