Provider Demographics
NPI:1316573884
Name:GARDENHIRE-KOGER, HEATHER L (BA, LMT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:GARDENHIRE-KOGER
Suffix:
Gender:F
Credentials:BA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 N BUTLER AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2362
Mailing Address - Country:US
Mailing Address - Phone:505-793-1760
Mailing Address - Fax:
Practice Address - Street 1:3300 N BUTLER AVE STE 206
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2362
Practice Address - Country:US
Practice Address - Phone:505-793-1760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMT8310225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist