Provider Demographics
NPI:1598913535
Name:SKELLY, HEATHER A (ATC,L)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:SKELLY
Suffix:
Gender:F
Credentials:ATC,L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5266 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:KNOX
Mailing Address - State:IN
Mailing Address - Zip Code:46534-7602
Mailing Address - Country:US
Mailing Address - Phone:574-772-3360
Mailing Address - Fax:
Practice Address - Street 1:2855 MILLER DR STE 105
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-8091
Practice Address - Country:US
Practice Address - Phone:574-941-1055
Practice Address - Fax:574-941-1083
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000870A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer