Provider Demographics
NPI:1396040507
Name:SMITH, HEATHER C (PT, CHT)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT, CHT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:CHRISTINE
Other - Last Name:DELUCIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:5401 NETHERBY LN STE 302
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7363
Practice Address - Country:US
Practice Address - Phone:843-225-5211
Practice Address - Fax:843-225-5513
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018958-1225100000X
SC11724225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02299067Medicaid
NYP02503Medicare PIN