Provider Demographics
NPI:1467557116
Name:SHATTUCK, HEATHER MARY (PTMS)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MARY
Last Name:SHATTUCK
Suffix:
Gender:F
Credentials:PTMS
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:MARY
Other - Last Name:KENYON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTMS
Mailing Address - Street 1:35 COUNTY ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642
Mailing Address - Country:US
Mailing Address - Phone:315-578-2849
Mailing Address - Fax:315-782-6612
Practice Address - Street 1:GAFFNEY DRIVE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-788-2730
Practice Address - Fax:315-782-6612
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0226661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist