Provider Demographics
NPI:1508317785
Name:HETH, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:HETH
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 1:151 PIONEER LN
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-2557
Mailing Address - Country:US
Mailing Address - Phone:760-872-1000
Mailing Address - Fax:
Practice Address - Street 1:151 PIONEER LN
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2557
Practice Address - Country:US
Practice Address - Phone:760-872-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28025225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist