Provider Demographics
NPI:1487005955
Name:HEIDEL, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:HEIDEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 144TH PL SE
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1340
Mailing Address - Country:US
Mailing Address - Phone:425-772-9241
Mailing Address - Fax:
Practice Address - Street 1:1401 144TH PL SE
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1340
Practice Address - Country:US
Practice Address - Phone:425-772-9241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60160216225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist