Provider Demographics
NPI:1114246469
Name:SMITH, HEATHER DIANE (LMT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DIANE
Last Name:SMITH
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 1:1692 E 1030 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-3006
Mailing Address - Country:US
Mailing Address - Phone:435-994-1669
Mailing Address - Fax:435-797-1248
Practice Address - Street 1:1692 E 1030 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-3006
Practice Address - Country:US
Practice Address - Phone:435-994-1669
Practice Address - Fax:435-797-1248
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6477960-4701225700000X
TXMT019872225700000X
AZMT-09592225700000X
IL507805-06225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist