Provider Demographics
NPI:1043205131
Name:SMITH, HEIDI LABORE (PT, LAC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LABORE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 PITT ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-1962
Mailing Address - Country:US
Mailing Address - Phone:218-525-2095
Mailing Address - Fax:
Practice Address - Street 1:1827 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-2044
Practice Address - Country:US
Practice Address - Phone:218-724-3400
Practice Address - Fax:218-728-7991
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
MN1094171100000X
MN2113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171100000XOther Service ProvidersAcupuncturist
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN34B85PROtherPT, L.AC