Provider Demographics
NPI:1710431523
Name:WATERBURY, HEATHER (DPT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WATERBURY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:BODIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7324 NIAGARA LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-2655
Mailing Address - Country:US
Mailing Address - Phone:763-257-2920
Mailing Address - Fax:
Practice Address - Street 1:7324 NIAGARA LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-2655
Practice Address - Country:US
Practice Address - Phone:763-257-2920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2020-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61897225100000X
MN11795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist