Provider Demographics
NPI:1336116615
Name:PORTER, HEATHER ROAN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:ROAN
Last Name:PORTER
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 1:946 CATALINA DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5169
Mailing Address - Country:US
Mailing Address - Phone:618-610-4538
Mailing Address - Fax:
Practice Address - Street 1:1503 LINDELL BLVD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3837
Practice Address - Country:US
Practice Address - Phone:618-709-4125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-04
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-333225200000X
MO2020010583225200000X
IL160.008943225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant