Provider Demographics
NPI:1477930972
Name:HARDIN, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:HARDIN
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 1:7542 SW 128TH LN
Mailing Address - Street 2:
Mailing Address - City:LAKE BUTLER
Mailing Address - State:FL
Mailing Address - Zip Code:32054-7550
Mailing Address - Country:US
Mailing Address - Phone:352-316-9868
Mailing Address - Fax:
Practice Address - Street 1:7542 SW 128TH LN
Practice Address - Street 2:
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054-7550
Practice Address - Country:US
Practice Address - Phone:352-316-9868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 24585225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant