Provider Demographics
NPI:1891824488
Name:BURGESS, HEATHER S (MSR-PT)
Entity Type:Individual
Prefix:MISS
First Name:HEATHER
Middle Name:S
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MSR-PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BRANDYBROOK LN
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2735
Mailing Address - Country:US
Mailing Address - Phone:843-412-3589
Mailing Address - Fax:
Practice Address - Street 1:507 WATTS AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-4357
Practice Address - Country:US
Practice Address - Phone:864-313-1219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4704225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist