Provider Demographics
NPI:1417526104
Name:CALBREATH, HEATHER CORRINE (PTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:CORRINE
Last Name:CALBREATH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6979 CREEKVIEW TRL APT 204
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-2462
Mailing Address - Country:US
Mailing Address - Phone:314-348-7241
Mailing Address - Fax:
Practice Address - Street 1:9645 BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-6521
Practice Address - Country:US
Practice Address - Phone:314-968-5460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020036131225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant