Provider Demographics
NPI:1679903140
Name:WOOD, HEIDI (PT)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 50469
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0469
Mailing Address - Country:US
Mailing Address - Phone:530-778-0200
Mailing Address - Fax:
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:#123
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5937
Practice Address - Country:US
Practice Address - Phone:907-455-4401
Practice Address - Fax:907-455-4402
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK2670OtherLICENCE