Provider Demographics
NPI:1821502386
Name:FOWLER, HEATHER ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELIZABETH
Last Name:FOWLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1302
Mailing Address - Country:US
Mailing Address - Phone:217-725-6597
Mailing Address - Fax:
Practice Address - Street 1:107 S 7TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1302
Practice Address - Country:US
Practice Address - Phone:217-725-6597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227007043225700000X
IL227.007043225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty