Provider Demographics
NPI:1679613426
Name:MARTIN, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20479 MALTA DR
Mailing Address - Street 2:
Mailing Address - City:BUCKLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64631-7210
Mailing Address - Country:US
Mailing Address - Phone:660-695-3619
Mailing Address - Fax:
Practice Address - Street 1:124A N PERSHING DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-2736
Practice Address - Country:US
Practice Address - Phone:660-258-2159
Practice Address - Fax:660-258-2190
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist