Provider Demographics
NPI:1679888705
Name:BELISLE, HEATHER A (LMP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:BELISLE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:A
Other - Last Name:FISHBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:1431 188TH ST NE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-5400
Mailing Address - Country:US
Mailing Address - Phone:425-531-1592
Mailing Address - Fax:
Practice Address - Street 1:20124 BALLINGER WAY NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-1117
Practice Address - Country:US
Practice Address - Phone:206-366-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60129779225700000X
WA60129779172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist