Provider Demographics
NPI:1144792748
Name:CANTWELL, HEATHER MARIA
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIA
Last Name:CANTWELL
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 1:305 N NELSON ST
Mailing Address - Street 2:
Mailing Address - City:POTTERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48876-8713
Mailing Address - Country:US
Mailing Address - Phone:517-648-1646
Mailing Address - Fax:
Practice Address - Street 1:2815 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3495
Practice Address - Country:US
Practice Address - Phone:517-975-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002604225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant