Provider Demographics
NPI:1366637209
Name:SMITH, HEATHER LYN-NIEBOER (ATC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYN-NIEBOER
Last Name:SMITH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYN
Other - Last Name:NIEBOER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2140 BAUER RD
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9539
Mailing Address - Country:US
Mailing Address - Phone:616-457-8454
Mailing Address - Fax:
Practice Address - Street 1:2140 BAUER RD
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-9539
Practice Address - Country:US
Practice Address - Phone:616-457-8454
Practice Address - Fax:616-457-8441
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2014-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010007122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer