Provider Demographics
NPI:1376304808
Name:HEISEL, RACHAEL NICOLE JO
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:NICOLE JO
Last Name:HEISEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 9TH AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-4125
Mailing Address - Country:US
Mailing Address - Phone:720-609-4439
Mailing Address - Fax:
Practice Address - Street 1:1800 30TH ST STE 119
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1088
Practice Address - Country:US
Practice Address - Phone:303-444-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0025355225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist