Provider Demographics
NPI:1710274113
Name:TACK, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:TACK
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 1:1944 N HERCULES AVE STE C
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-4403
Mailing Address - Country:US
Mailing Address - Phone:727-442-9670
Mailing Address - Fax:
Practice Address - Street 1:1944 N HERCULES AVE STE C
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33763-4403
Practice Address - Country:US
Practice Address - Phone:727-442-9670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26586225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist