Provider Demographics
NPI:1629388491
Name:DESMOND, HEATHER MARIE (PTA)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:MARIE
Last Name:DESMOND
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 COUNTY HIGHWAY 114
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13452-2307
Mailing Address - Country:US
Mailing Address - Phone:518-568-7963
Mailing Address - Fax:
Practice Address - Street 1:405 COUNTY HIGHWAY 114
Practice Address - Street 2:
Practice Address - City:ST JOHNSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13452-2307
Practice Address - Country:US
Practice Address - Phone:518-568-3102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004438-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant