Provider Demographics
NPI:1326281635
Name:BRUMLEVE, HEATHER WALSTON (LMT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:WALSTON
Last Name:BRUMLEVE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:WALSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4020 HETH WASHINGTON RD SW
Mailing Address - Street 2:
Mailing Address - City:CENTRAL
Mailing Address - State:IN
Mailing Address - Zip Code:47110-7822
Mailing Address - Country:US
Mailing Address - Phone:812-732-4696
Mailing Address - Fax:812-732-4696
Practice Address - Street 1:4020 HETH WASHINGTON RD SW
Practice Address - Street 2:
Practice Address - City:CENTRAL
Practice Address - State:IN
Practice Address - Zip Code:47110-7822
Practice Address - Country:US
Practice Address - Phone:812-732-4696
Practice Address - Fax:812-732-4696
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 2563225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist