Provider Demographics
NPI:1366869356
Name:FOGELMAN, HEATHER JEAN (PT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:JEAN
Last Name:FOGELMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MISSOURI VALLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51555-1102
Mailing Address - Country:US
Mailing Address - Phone:712-642-2179
Mailing Address - Fax:712-642-3510
Practice Address - Street 1:518 LINCOLNWAY ST
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:IA
Practice Address - Zip Code:51579-1238
Practice Address - Country:US
Practice Address - Phone:712-647-2566
Practice Address - Fax:712-647-2964
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist