Provider Demographics
NPI:1093116261
Name:THOMPSON, HEATHER SHANNON (LMT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:SHANNON
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:PINGREE GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-9192
Mailing Address - Country:US
Mailing Address - Phone:847-542-2723
Mailing Address - Fax:
Practice Address - Street 1:12165 REGENCY PKWY
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-7644
Practice Address - Country:US
Practice Address - Phone:847-515-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227011824225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist