Provider Demographics
NPI:1063825164
Name:THOMKA-GAZDIK, HEATHER ANNE WREDE
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:ANNE WREDE
Last Name:THOMKA-GAZDIK
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 1:535 OCEAN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4970
Mailing Address - Country:US
Mailing Address - Phone:207-232-6088
Mailing Address - Fax:
Practice Address - Street 1:535 OCEAN AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4970
Practice Address - Country:US
Practice Address - Phone:207-232-6088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT5232225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist