Provider Demographics
NPI:1275968612
Name:TABATA, HEATHER MICHELLE (DPT)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:MICHELLE
Last Name:TABATA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 KATE IRELAND DR
Mailing Address - Street 2:
Mailing Address - City:HYDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41749-9071
Mailing Address - Country:US
Mailing Address - Phone:606-672-2901
Mailing Address - Fax:606-672-1966
Practice Address - Street 1:130 KATE IRELAND DR
Practice Address - Street 2:
Practice Address - City:HYDEN
Practice Address - State:KY
Practice Address - Zip Code:41749-9071
Practice Address - Country:US
Practice Address - Phone:606-672-2901
Practice Address - Fax:606-672-1966
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT006275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist