Provider Demographics
NPI:1790811560
Name:DECKELBAUM, HEATHER ANNE (MS, CCC)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:ANNE
Last Name:DECKELBAUM
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 GRANT ST STE K
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4700
Mailing Address - Country:US
Mailing Address - Phone:703-904-8334
Mailing Address - Fax:
Practice Address - Street 1:626 GRANT ST STE K
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4700
Practice Address - Country:US
Practice Address - Phone:703-904-8334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005031235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist