Provider Demographics
NPI:1003078445
Name:HEATLEY, THOMAS W (MS CCC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:HEATLEY
Suffix:
Gender:M
Credentials:MS CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24451 HEALTH CTR DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92652-3689
Mailing Address - Country:US
Mailing Address - Phone:949-837-4500
Mailing Address - Fax:949-699-0535
Practice Address - Street 1:24451 HEALTH CTR DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92652-3689
Practice Address - Country:US
Practice Address - Phone:949-837-4500
Practice Address - Fax:949-699-0535
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 5397235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist