Provider Demographics
NPI:1689706558
Name:DALLAS, HEATHER J
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:J
Last Name:DALLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12510 VAN NUYS BLVD,
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331
Practice Address - Country:US
Practice Address - Phone:310-418-8857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner