Provider Demographics
NPI:1609386622
Name:CAMPBELL, HEATHER MARIE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MARIE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 CASA GRANDE RD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5706
Mailing Address - Country:US
Mailing Address - Phone:707-763-3385
Mailing Address - Fax:
Practice Address - Street 1:333 CASA GRANDE RD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-5706
Practice Address - Country:US
Practice Address - Phone:707-763-3385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0891024412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer