Provider Demographics
NPI:1609100635
Name:HEAVEN, CHANDRA DENISE (LPT)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:DENISE
Last Name:HEAVEN
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:CHANDRA
Other - Middle Name:DENISE
Other - Last Name:HEAVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPT
Mailing Address - Street 1:3608 CHAGFORD LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-4619
Mailing Address - Country:US
Mailing Address - Phone:301-437-0444
Mailing Address - Fax:
Practice Address - Street 1:1700 PAMALEE DR
Practice Address - Street 2:HIGHLAND HOUSE SNF
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-1700
Practice Address - Country:US
Practice Address - Phone:910-488-2295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11369225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist