Provider Demographics
NPI:1689071367
Name:CARROLL, HEATHER COLLEEN (ATC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:COLLEEN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7331 ZEPHYR PL
Mailing Address - Street 2:2E
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63143-2221
Mailing Address - Country:US
Mailing Address - Phone:702-375-5227
Mailing Address - Fax:
Practice Address - Street 1:2937 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-2713
Practice Address - Country:US
Practice Address - Phone:314-961-3804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080211312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer