Provider Demographics
NPI:1033668991
Name:REWALT, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:REWALT
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 1:15930 19 MILE RD
Mailing Address - Street 2:BUILDLING 200, SUITE 150
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1155
Mailing Address - Country:US
Mailing Address - Phone:586-464-0175
Mailing Address - Fax:
Practice Address - Street 1:15930 19 MILE RD
Practice Address - Street 2:BUILDLING 200, SUITE 150
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1155
Practice Address - Country:US
Practice Address - Phone:586-464-0175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other