Provider Demographics
NPI:1609517499
Name:RANDALL, HEATHER (LMT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 SKYRANCH DR
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-7524
Mailing Address - Country:US
Mailing Address - Phone:360-567-9768
Mailing Address - Fax:
Practice Address - Street 1:1013 LAKE ST STE 100
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-5002
Practice Address - Country:US
Practice Address - Phone:208-597-7597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-4722225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist