Provider Demographics
NPI:1700210739
Name:ROLAND, HEIDI ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:ELIZABETH
Last Name:ROLAND
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:PO BOX 290699
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-0699
Mailing Address - Country:US
Mailing Address - Phone:386-492-2986
Mailing Address - Fax:
Practice Address - Street 1:4550 S CLYDE MORRIS BLVD
Practice Address - Street 2:STE. D
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-5294
Practice Address - Country:US
Practice Address - Phone:386-492-2986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24237225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant