Provider Demographics
NPI:1528413697
Name:BOLEN, HEATHER (MSPT, CERT MDT)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:BOLEN
Suffix:
Gender:F
Credentials:MSPT, CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 22ND RD NW
Mailing Address - Street 2:
Mailing Address - City:LEBO
Mailing Address - State:KS
Mailing Address - Zip Code:66856-9324
Mailing Address - Country:US
Mailing Address - Phone:620-203-8652
Mailing Address - Fax:
Practice Address - Street 1:601 CROSS ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KS
Practice Address - Zip Code:66839-1105
Practice Address - Country:US
Practice Address - Phone:620-364-2117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03888225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist