Provider Demographics
NPI:1679810949
Name:ANDERSON, HEATHER RENEE (PTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:RENEE
Last Name:ANDERSON
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 1:168 LOCUST GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:KY
Mailing Address - Zip Code:40311-9125
Mailing Address - Country:US
Mailing Address - Phone:859-473-0180
Mailing Address - Fax:
Practice Address - Street 1:168 LOCUST GROVE RD
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:KY
Practice Address - Zip Code:40311-9125
Practice Address - Country:US
Practice Address - Phone:859-473-0180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02410225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant