Provider Demographics
NPI:1376835116
Name:MAYO, HEIDI LYNNE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:LYNNE
Last Name:MAYO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 BREWERTON RD
Mailing Address - Street 2:
Mailing Address - City:MATTYDALE
Mailing Address - State:NY
Mailing Address - Zip Code:13211-1147
Mailing Address - Country:US
Mailing Address - Phone:315-455-9355
Mailing Address - Fax:
Practice Address - Street 1:2605 BREWERTON RD
Practice Address - Street 2:
Practice Address - City:MATTYDALE
Practice Address - State:NY
Practice Address - Zip Code:13211-1147
Practice Address - Country:US
Practice Address - Phone:315-455-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022078174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist