Provider Demographics
NPI:1225562309
Name:HEFNER, LAURA (PTA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:HEFNER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 ASHFORD DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:435 BUCKHANNON PIKE
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-4307
Practice Address - Country:US
Practice Address - Phone:304-622-1600
Practice Address - Fax:304-622-4747
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA2343225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant