Provider Demographics
NPI:1568617744
Name:MILLS, HEATHER DEANNA (CMT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DEANNA
Last Name:MILLS
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5080
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90409-5080
Mailing Address - Country:US
Mailing Address - Phone:310-467-1102
Mailing Address - Fax:
Practice Address - Street 1:3107 LIVONIA AVE
Practice Address - Street 2:UNIT 1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034
Practice Address - Country:US
Practice Address - Phone:310-467-1102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15012225700000X
CA190225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist