Provider Demographics
NPI:1619048337
Name:VANDEBURG, HEATHER L (LAC)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:L
Last Name:VANDEBURG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-1327
Mailing Address - Country:US
Mailing Address - Phone:815-751-6424
Mailing Address - Fax:
Practice Address - Street 1:547 W STATE ST
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-1327
Practice Address - Country:US
Practice Address - Phone:815-751-6424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198-000562171100000X
AZ0404171100000X
WAAC00002618171100000X
CO1065171100000X
WI434-055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist