Provider Demographics
NPI:1295190601
Name:WILDSTEIN, HEATHER (LMT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WILDSTEIN
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 1:1244 EAST MARCELLA LANE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295
Mailing Address - Country:US
Mailing Address - Phone:602-733-0748
Mailing Address - Fax:
Practice Address - Street 1:1244 E MARCELLA LN
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1765
Practice Address - Country:US
Practice Address - Phone:602-733-0748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17668225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist