Provider Demographics
NPI:1659605350
Name:HEIDEMANN, STEPHANIE C (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:C
Last Name:HEIDEMANN
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 1:1790 POMELO DRIVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-2716
Mailing Address - Country:US
Mailing Address - Phone:941-493-8596
Mailing Address - Fax:941-493-8596
Practice Address - Street 1:2248 OUTER DRIVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231
Practice Address - Country:US
Practice Address - Phone:941-493-8596
Practice Address - Fax:941-493-8596
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA44879225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist