Provider Demographics
NPI:1447762778
Name:LAIDLER, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:LAIDLER
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 1:125 E CAPAC RD
Mailing Address - Street 2:
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-1111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 E CAPAC RD
Practice Address - Street 2:
Practice Address - City:IMLAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48444-4844
Practice Address - Country:US
Practice Address - Phone:810-724-0996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501007089225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist